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Wu Y, Lu J, Wang T, Zhu X, Xue J, You L. Association of frequent intradialytic hypotension with the clinical outcomes of patients on hemodialysis: a prospective cohort study. Ren Fail 2024; 46:2296612. [PMID: 38178566 PMCID: PMC10773638 DOI: 10.1080/0886022x.2023.2296612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 12/12/2023] [Indexed: 01/06/2024] Open
Abstract
Intradialytic hypotension (IDH) is a common complication of hemodialysis (HD), but there is no consensus on its definition. In 2015, Flythe proposed a definition of IDH (Definition 1 in this study): nadir systolic blood pressure (SBP) <90 mmHg during hemodialysis for patients with pre-dialysis SBP <159 mmHg, and nadir SBP <100 mmHg during hemodialysis for patients with pre-dialysis SBP ≥160 mmHg. This prospective observational cohort study investigated the association of frequent IDH based on Definition 1 with clinical outcomes and compared Definition 1 with a commonly used definition (nadir SBP <90 mmHg during hemodialysis, Definition 2). The incidence of IDH was observed over a 3-month exposure assessment period. Patients with IDH events ≥30% were classified as 'frequent IDH'; the others were 'infrequent IDH'. All-cause mortality, cardiovascular mortality, and all-cause hospitalization events were followed up for 36 months. This study enrolled 163 HD patients. The incidence of IDH was 11.1% according to Definition 1 and 10.5% according to Definition 2. The Kaplan-Meier curves showed that frequent IDH patients had higher risks of all-cause mortality (p = 0.009, Definition 1; p = 0.002, Definition 2) and cardiovascular mortality (p = 0.021, Definition 1). Multivariable Cox regression analysis indicated that frequent IDH was independently associated with a higher risk of all-cause mortality (Model 1: HR = 2.553, 95%CI 1.334-4.886, p = 0.005; Model 2: HR = 2.406, 95%CI 1.253-4.621, p = 0.008). In conclusion, HD patients classified as frequent IDH are at a greater risk of all-cause mortality. This highlights the significance of acknowledging and proactively managing frequent IDH within the HD patients.
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Affiliation(s)
- Yuanhao Wu
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Jianda Lu
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Tingting Wang
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Xiaoye Zhu
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Jun Xue
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Li You
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
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2
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Stuard S, Ridel C, Cioffi M, Trost-Rupnik A, Gurevich K, Bojic M, Karibayev Y, Mohebbi N, Marcinkowski W, Kupres V, Maslovaric J, Antebi A, Ponce P, Nada M, Salvador MEB, Rosenberger J, Jirka T, Enden K, Novakivskyy V, Voiculescu D, Pachmann M, Arkossy O. Hemodialysis Procedures for Stable Incident and Prevalent Patients Optimize Hemodynamic Stability, Dialysis Dose, Electrolytes, and Fluid Balance. J Clin Med 2024; 13:3211. [PMID: 38892922 PMCID: PMC11173331 DOI: 10.3390/jcm13113211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 05/14/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
The demographic profile of patients transitioning from chronic kidney disease to kidney replacement therapy is changing, with a higher prevalence of aging patients with multiple comorbidities such as diabetes mellitus and heart failure. Cardiovascular disease remains the leading cause of mortality in this population, exacerbated by the cardiovascular stress imposed by the HD procedure. The first year after transitioning to hemodialysis is associated with increased risks of hospitalization and mortality, particularly within the first 90-120 days, with greater vulnerability observed among the elderly. Based on data from clinics in Fresenius Medical Care Europe, Middle East, and Africa NephroCare, this review aims to optimize hemodialysis procedures to reduce mortality risk in stable incident and prevalent patients. It addresses critical aspects such as treatment duration, frequency, choice of dialysis membrane, dialysate composition, blood and dialysate flow rates, electrolyte composition, temperature control, target weight management, dialysis adequacy, and additional protocols, with a focus on mitigating prevalent intradialytic complications, particularly intradialytic hypotension prevention.
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Affiliation(s)
- Stefano Stuard
- FME Global Medical Office, 61352 Bad Homburg, Germany; (M.P.); (O.A.)
| | | | | | | | | | - Marija Bojic
- FME Global Medical Office, 75400 Zvornik, Bosnia and Herzegovina;
| | | | | | | | | | | | - Alon Antebi
- FME Global Medical Office, Ra’anana 4366411, Israel;
| | - Pedro Ponce
- FME Global Medical Office, 1750-233 Lisboa, Portugal;
| | - Mamdouh Nada
- FME Global Medical Office, Riyadh 12472, Saudi Arabia;
| | | | | | - Tomas Jirka
- FME Global Medical Office, 16000 Praha, Czech Republic;
| | - Kira Enden
- FME Global Medical Office, 00380 Helsinki, Finland;
| | | | | | - Martin Pachmann
- FME Global Medical Office, 61352 Bad Homburg, Germany; (M.P.); (O.A.)
| | - Otto Arkossy
- FME Global Medical Office, 61352 Bad Homburg, Germany; (M.P.); (O.A.)
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3
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Canaud B, Davenport A, Leray-Moragues H, Morena-Carrere M, Cristol JP, Kooman J, Kotanko P. Digital Health Support: Current Status and Future Development for Enhancing Dialysis Patient Care and Empowering Patients. Toxins (Basel) 2024; 16:211. [PMID: 38787063 PMCID: PMC11125858 DOI: 10.3390/toxins16050211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/18/2024] [Accepted: 04/27/2024] [Indexed: 05/25/2024] Open
Abstract
Chronic kidney disease poses a growing global health concern, as an increasing number of patients progress to end-stage kidney disease requiring kidney replacement therapy, presenting various challenges including shortage of care givers and cost-related issues. In this narrative essay, we explore innovative strategies based on in-depth literature analysis that may help healthcare systems face these challenges, with a focus on digital health technologies (DHTs), to enhance removal and ensure better control of broader spectrum of uremic toxins, to optimize resources, improve care and outcomes, and empower patients. Therefore, alternative strategies, such as self-care dialysis, home-based dialysis with the support of teledialysis, need to be developed. Managing ESKD requires an improvement in patient management, emphasizing patient education, caregiver knowledge, and robust digital support systems. The solution involves leveraging DHTs to automate HD, implement automated algorithm-driven controlled HD, remotely monitor patients, provide health education, and enable caregivers with data-driven decision-making. These technologies, including artificial intelligence, aim to enhance care quality, reduce practice variations, and improve treatment outcomes whilst supporting personalized kidney replacement therapy. This narrative essay offers an update on currently available digital health technologies used in the management of HD patients and envisions future technologies that, through digital solutions, potentially empower patients and will more effectively support their HD treatments.
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Affiliation(s)
- Bernard Canaud
- School of Medicine, Montpellier University, 9 Rue des Carmelites, 34090 Montpellier, France
- Fondation Charles Mion, AIDER-SANTE, 34000 Montpellier, France; (H.L.-M.)
- MTX Consulting International, 34090 Montpellier, France
| | - Andrew Davenport
- UCL Department of Renal Medicine, University College London, London WC1E 6BT, UK;
| | | | - Marion Morena-Carrere
- PhyMedExp, Department of Biochemistry and Hormonology, INSERM, CNRS, University Hospital Center of Montpellier, University of Montpellier, 34000 Montpellier, France;
| | - Jean Paul Cristol
- Fondation Charles Mion, AIDER-SANTE, 34000 Montpellier, France; (H.L.-M.)
- PhyMedExp, Department of Biochemistry and Hormonology, INSERM, CNRS, University Hospital Center of Montpellier, University of Montpellier, 34000 Montpellier, France;
| | - Jeroen Kooman
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
| | - Peter Kotanko
- Renal Research Institute, Icahn University, New York, NY 10065, USA;
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4
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Gullapudi VRL, Cox EF, Buchanan CE, Canaud B, White K, Taal MW, Selby NM, Francis ST. Randomized trial comparing standard versus thermocontrolled haemodialysis using intradialytic cardiac, brain and renal magnetic resonance imaging. Nephrol Dial Transplant 2024; 39:233-241. [PMID: 37433572 PMCID: PMC10828207 DOI: 10.1093/ndt/gfad150] [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: 03/29/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Ischaemic end-organ damage during haemodialysis (HD) is a significant problem that may be ameliorated by intradialytic cooling. A randomised trial was performed to compare standard HD (SHD; dialysate temperature 37°C) and programmed cooling of the dialysate [thermocontrolled HD (TCHD)] using multiparametric magnetic resonance imaging (MRI) to assess structural, functional and blood flow changes in the heart, brain and kidneys. METHODS Prevalent HD patients were randomly allocated to receive either SHD or TCHD for 2 weeks before undergoing serial MRI at four time points: pre-, during (30 min and 180 min) and post-dialysis. MRI measures include cardiac index, myocardial strain, longitudinal relaxation time (T1), myocardial perfusion, internal carotid and basilar artery flow, grey matter perfusion and total kidney volume. Participants then crossed to the other modality to repeat the study protocol. RESULTS Eleven participants completed the study. Separation in blood temperature between TCHD (-0.1 ± 0.3°C) and SHD (+0.3 ± 0.2°C; P = .022) was observed, although there was no difference in tympanic temperature changes between arms. There were significant intradialytic reductions in cardiac index, cardiac contractility (left ventricular strain), left carotid and basilar artery blood flow velocities, total kidney volume, longitudinal relaxation time (T1) of the renal cortex and transverse relaxation rate (T2*) of the renal cortex and medulla, but no differences between arms. Pre-dialysis T1 of the myocardium and left ventricular wall mass index were lower after 2 weeks of TCHD compared with SHD [1266 ms (interquartile range 1250-1291) versus 1311 ± 58 ms, P = .02; 66 ± 22 g/m2 versus 72 ± 23 g/m2, P = .004]. CONCLUSIONS HD adversely affects cardiac function, reduces carotid and basilar artery blood flow and total kidney volume, but mild dialysate cooling using a biofeedback module did not result in differences in intradialytic MRI measures compared with SHD.
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Affiliation(s)
- Venkata R Latha Gullapudi
- Centre for Kidney Research and Innovation, University of Nottingham, Derby, UK
- Department of Renal Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Eleanor F Cox
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Charlotte E Buchanan
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham, UK
| | - Bernard Canaud
- Global Medical Office, Fresenius Medical Care, Bad Homburg, Germany
| | - Kelly White
- Department of Renal Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Maarten W Taal
- Centre for Kidney Research and Innovation, University of Nottingham, Derby, UK
- Department of Renal Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, University of Nottingham, Derby, UK
- Department of Renal Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Susan T Francis
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
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5
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Hull KL, McIntyre C, Burton JO. Does cooled dialysate still have a role in reducing intradialytic stress? Implications of the MyTEMP trial. Curr Opin Nephrol Hypertens 2023; 32:537-543. [PMID: 37753645 DOI: 10.1097/mnh.0000000000000917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
PURPOSE OF REVIEW There is an excess of cardiovascular morbidity and mortality in the maintenance haemodialysis population. Targeting traditional risk factors (e.g. hypercholesterolaemia) do not improve cardiovascular outcomes. Repeated myocardial stunning during haemodialysis is an important nontraditional risk, resulting in pathological cardiac remodelling and fibrosis. This review explores dialysate cooling as a management strategy to promote haemodynamic stability, reduce myocardial injury, and improve cardiovascular disease outcomes for individuals receiving maintenance haemodialysis. RECENT FINDINGS Observational data and small interventional studies demonstrate dialysate cooling has the potential to reduce end-organ damage and provide cardioprotection, renal protection and neuroprotection compared with standard care. These data are limited by the small sample sizes, short follow-up times and lack of long-term patient important outcomes. The MyTEMP study, a multicentre pragmatic randomized controlled trial, demonstrated cooled dialysate (0.5°C below body temperature) vs. standard care did not improve cardiovascular outcomes for prevalent haemodialysis patients. SUMMARY Dialysate cooling has been widely adopted into routine clinical practice; the MyTEMP study challenges the unit-level approach to implementing dialysate cooling. Due to methodological limitations, the absence of other important patient outcome measures, and lack of granularity of patient-level data, dialysate cooling should not be hastily removed from all dialysis care and warrants further research.
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Affiliation(s)
- Katherine L Hull
- Department of Cardiovascular Sciences, University of Leicester
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Chris McIntyre
- Lilibeth Caberto Kidney Clinical Research Unit, Lawson Health Research Institute
- Department of Medical Biophysics, Western University, London, Ontario, Canada
| | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
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6
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Elemshaty A, Sayed-Ahmed N, Mesbah A, Nassar MK. Could cooling dialysate improve inflammatory and nutritional status of hemodialysis patients? BMC Nephrol 2023; 24:255. [PMID: 37626325 PMCID: PMC10464236 DOI: 10.1186/s12882-023-03305-z] [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: 03/23/2023] [Accepted: 08/20/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND It has been shown that dialysate cooling (lowering the dialysate temperature to 0.5 °C below central body temperature) reduces the incidence of intradialytic hypotension. Other influences on hemodialysis patients, however, have not been adequately investigated. The purpose of this study was to determine the impact of individualized dialysate cooling on nutritional and inflammatory parameters in chronic hemodialysis (HD) patients. METHODS Seventy HD patients were separated into two groups: group A: (control group) standard dialysate temperature was 37 °C, and group B: (intervention group) dialysate temperature was 0.5 °C below core body temperature. In addition to routine laboratory tests, blood pressure, anthropometric measurements, inflammatory markers, and the malnutrition inflammation score (MIS) were calculated. RESULTS After six months of dialysate cooling, intradialytic hypotension episodes were much less prevalent in the intervention group (p = 0.001). Serum ferritin, transferrin saturation (TSAT), high sensitive C-reactive protein (HS-CRP), and Interleukin-6 (IL-6) reduced following dialysate cooling, whereas serum albumin rose. In the control group, IL-6 dropped but serum ferritin, TSAT, albumin, and HS-CRP rose. In both groups, hemoglobin levels dropped, and erythrocyte sedimentation rate (ESR) rose, both groups' midarm muscle circumference and MIS worsened. CONCLUSION Cold dialysate decreased intradialytic hypotension with no significant improvement of the nutritional and inflammatory surrogates. However, more studies including larger number of patients with longer duration of follow up are required to adequately assess its effect on inflammation and nutrition in chronic hemodialysis patients.
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Affiliation(s)
- Asmaa Elemshaty
- Mansoura Nephrology & Dialysis Unit (MNDU), Department of Internal Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Nagy Sayed-Ahmed
- Mansoura Nephrology & Dialysis Unit (MNDU), Department of Internal Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
- Department of Internal Medicine, Faculty of Medicine, Horus University, New Damietta, Egypt
| | - Abeer Mesbah
- Clinical Pathology department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohammed Kamal Nassar
- Mansoura Nephrology & Dialysis Unit (MNDU), Department of Internal Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
- Department of Internal Medicine, Faculty of Medicine, Horus University, New Damietta, Egypt.
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7
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Hypertension and cardiomyopathy associated with chronic kidney disease: epidemiology, pathogenesis and treatment considerations. J Hum Hypertens 2023; 37:1-19. [PMID: 36138105 PMCID: PMC9831930 DOI: 10.1038/s41371-022-00751-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/09/2022] [Accepted: 08/31/2022] [Indexed: 01/31/2023]
Abstract
Chronic kidney disease (CKD) is a complex condition with a prevalence of 10-15% worldwide. An inverse-graded relationship exists between cardiovascular events and mortality with kidney function which is independent of age, sex, and other risk factors. The proportion of deaths due to heart failure and sudden cardiac death increase with progression of chronic kidney disease with relatively fewer deaths from atheromatous, vasculo-occlusive processes. This phenomenon can largely be explained by the increased prevalence of CKD-associated cardiomyopathy with worsening kidney function. The key features of CKD-associated cardiomyopathy are increased left ventricular mass and left ventricular hypertrophy, diastolic and systolic left ventricular dysfunction, and profound cardiac fibrosis on histology. While these features have predominantly been described in patients with advanced kidney disease on dialysis treatment, patients with only mild to moderate renal impairment already exhibit structural and functional changes consistent with CKD-associated cardiomyopathy. In this review we discuss the key drivers of CKD-associated cardiomyopathy and the key role of hypertension in its pathogenesis. We also evaluate existing, as well as developing therapies in the treatment of CKD-associated cardiomyopathy.
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8
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Mark PB, Mangion K, Rankin AJ, Rutherford E, Lang NN, Petrie MC, Stoumpos S, Patel RK. Left ventricular dysfunction with preserved ejection fraction: the most common left ventricular disorder in chronic kidney disease patients. Clin Kidney J 2022; 15:2186-2199. [PMID: 36381379 PMCID: PMC9664574 DOI: 10.1093/ckj/sfac146] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Indexed: 08/25/2023] Open
Abstract
Chronic kidney disease (CKD) is a risk factor for premature cardiovascular disease. As kidney function declines, the presence of left ventricular abnormalities increases such that by the time kidney replacement therapy is required with dialysis or kidney transplantation, more than two-thirds of patients have left ventricular hypertrophy. Historically, much research in nephrology has focussed on the structural and functional aspects of cardiac disease in CKD, particularly using echocardiography to describe these abnormalities. There is a need to translate knowledge around these imaging findings to clinical outcomes such as unplanned hospital admission with heart failure and premature cardiovascular death. Left ventricular hypertrophy and cardiac fibrosis, which are common in CKD, predispose to the clinical syndrome of heart failure with preserved left ventricular ejection fraction (HFpEF). There is a bidirectional relationship between CKD and HFpEF, whereby CKD is a risk factor for HFpEF and CKD impacts outcomes for patients with HFpEF. There have been major improvements in outcomes for patients with heart failure and reduced left ventricular ejection fraction as a result of several large randomized controlled trials. Finding therapy for HFpEF has been more elusive, although recent data suggest that sodium-glucose cotransporter 2 inhibition offers a novel evidence-based class of therapy that improves outcomes in HFpEF. These observations have emerged as this class of drugs has also become the standard of care for many patients with proteinuric CKD, suggesting that there is now hope for addressing the combination of HFpEF and CKD in parallel. In this review we summarize the epidemiology, pathophysiology, diagnostic strategies and treatment of HFpEF with a focus on patients with CKD.
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Affiliation(s)
- Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Kenneth Mangion
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Alastair J Rankin
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Elaine Rutherford
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Nephrology, NHS Dumfries and Galloway, Dumfries, UK
| | - Ninian N Lang
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Sokratis Stoumpos
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Rajan K Patel
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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9
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Allinovi M, Palazzini G, Lugli G, Gianassi I, Dallari L, Laudicina S, Gregori M, Rossi F, Giannerini D, Cutruzzulà R, Dervishi E, Biagini M, Cirami CL. Pre-Dialysis B-Line Quantification at Lung Ultrasound Is a Useful Method for Evaluating the Dry Weight and Predicting the Risk of Intradialytic Hypotension. Diagnostics (Basel) 2022; 12:diagnostics12122990. [PMID: 36552997 PMCID: PMC9776885 DOI: 10.3390/diagnostics12122990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/22/2022] [Accepted: 11/26/2022] [Indexed: 12/02/2022] Open
Abstract
Intradialytic hypotension (IDH) is a frequent and well-known complication of hemodialysis, occurring in about one third of patients. An integrated approach with different methods is needed to minimize IDH episodes and their complications. In this prospective observational study, recruited patients underwent a multiparametric evaluation of fluid status through a lung ultrasound (LUS) with the quantification of B-lines, a physical examination, blood pressure, NT-proBNP and chest X-rays. The evaluation took place immediately before and at the end of the dialysis session, and the patients were divided into IDH and no-IDH groups. We recruited a total of 107 patients. A pre-dialysis B-line number ≥ 15 showed a high sensitivity in fluid overload diagnosis (94.5%), even higher than a chest X-ray (78%) or physical examination (72%) alone. The identification at the beginning of dialysis of <8 B-lines in the overall cohort or <20 B-lines in patients with NYHA 3−4 class are optimal thresholds for identifying those patients at higher risk of experiencing an IDH episode. In the multivariable analysis, the NYHA class, a low pre-dialysis systolic BP and a low pre-dialysis B-line number were independent risk factors for IDH. At the beginning of dialysis, the B-line quantification at LUS is a valuable and reliable method for evaluating fluid status and predicting IDH episodes. A post-dialysis B-line number <5 may allow for an understanding of whether the IDH episode was caused by dehydration, probably due to due to an overestimation of the dry weight.
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Affiliation(s)
- Marco Allinovi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
- Correspondence:
| | - Giulia Palazzini
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, 50121 Florence, Italy
| | - Gianmarco Lugli
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, 50121 Florence, Italy
- Nephrology Unit, Meyer Children’s Hospital, 50139 Florence, Italy
| | - Iacopo Gianassi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Lorenzo Dallari
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, 50121 Florence, Italy
| | - Selene Laudicina
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, 50121 Florence, Italy
| | - Marco Gregori
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, 33076 Bordeaux, France
| | - Francesco Rossi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Daniele Giannerini
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Roberta Cutruzzulà
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Egrina Dervishi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Maria Biagini
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Calogero Lino Cirami
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
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10
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Garg AX, Al-Jaishi AA, Dixon SN, Sontrop JM, Anderson SJ, Bagga A, Benjamin DS, Berry WAD, Blake PG, Chambers LC, Chan PCK, Delbrouck NF, Devereaux PJ, Goluch RJ, Gregor LH, Grimshaw JM, Hanson GJ, Illiescu EA, Jain AK, Killin L, Lok CE, Luo B, Mustafa RA, Nathoo BC, Nesrallah GE, Oliver MJ, Pandeya S, Parmar MS, Perkins DN, Presseau J, Rabin EZ, Sasal JT, Shulman TS, Smith DM, Sood M, Steele AW, Tam PYW, Tascona DJ, Wadehra DB, Wald R, Walsh M, Watson PA, Wodchis WP, Zager PG, Zwarenstein M, McIntyre CW. Personalised cooler dialysate for patients receiving maintenance haemodialysis (MyTEMP): a pragmatic, cluster-randomised trial. Lancet 2022; 400:1693-1703. [PMID: 36343653 DOI: 10.1016/s0140-6736(22)01805-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Haemodialysis centres have conventionally provided maintenance haemodialysis using a standard dialysate temperature (eg, 36·5°C) for all patients. Many centres now use cooler dialysate (eg, 36·0°C or lower) for potential cardiovascular benefits. We aimed to assess whether personalised cooler dialysate, implemented as centre-wide policy, reduced the risk of cardiovascular-related death or hospital admission compared with standard temperature dialysate. METHODS MyTEMP was a pragmatic, two-arm, parallel-group, registry-based, open-label, cluster-randomised, superiority trial done at haemodialysis centres in Ontario, Canada. Eligible centres provided maintenance haemodialysis to at least 15 patients a week, and the medical director of each centre had to confirm that their centre would deliver the assigned intervention. Using covariate-constrained randomisation, we allocated 84 centres (1:1) to use either personalised cooler dialysate (nurses set the dialysate temperature 0·5-0·9°C below each patient's measured pre-dialysis body temperature, with a lowest recommended dialysate temperature of 35·5°C), or standard temperature dialysate (36·5°C for all patients and treatments). Patients and health-care providers were not masked to the group assignment; however, the primary outcome was recorded in provincial databases by medical coders who were unaware of the trial or the centres' group assignment. The primary composite outcome was cardiovascular-related death or hospital admission with myocardial infarction, ischaemic stroke, or congestive heart failure during the 4-year trial period. Analysis was by intention to treat. The study is registered at ClinicalTrials.gov, NCT02628366. FINDINGS We assessed all of Ontario's 97 centres for inclusion into the study. Nine centres had less than 15 patients and one director requested that four of their seven centres not participate. 84 centres were recruited and on Feb 1, 2017, these centres were randomly assigned to administer personalised cooler dialysate (42 centres) or standard temperature dialysate (42 centres). The intervention period was from April 3, 2017, to March 31, 2021, and during this time the trial centres provided outpatient maintenance haemodialysis to 15 413 patients (about 4·3 million haemodialysis treatments). The mean dialysate temperature was 35·8°C in the cooler dialysate group and 36·4°C in the standard temperature group. The primary outcome occurred in 1711 (21·4%) of 8000 patients in the cooler dialysate group versus 1658 (22·4%) of 7413 patients in the standard temperature group (adjusted hazard ratio 1·00, 96% CI 0·89 to 1·11; p=0·93). The mean drop in intradialytic systolic blood pressure was 26·6 mm Hg in the cooler dialysate group and 27·1 mm Hg in the standard temperature group (mean difference -0·5 mm Hg, 99% CI -1·4 to 0·4; p=0·14). INTERPRETATION Centre-wide delivery of personalised cooler dialysate did not significantly reduce the risk of major cardiovascular events compared with standard temperature dialysate. The rising popularity of cooler dialysate is called into question by this study, and the risks and benefits of cooler dialysate in some patient populations should be clarified in future trials. FUNDING Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Renal Network, Ontario Strategy for Patient-Oriented Research Support Unit, Dialysis Clinic, Inc., ICES (formerly known as the Institute for Clinical Evaluative Sciences), Lawson Health Research Institute, and Western University.
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Selby NM, Taal MW. Evaluating the results of MyTEMP, a cluster randomised trial of lower temperature haemodialysis: the end of a cool idea? Lancet 2022; 400:1657-1659. [PMID: 36343652 DOI: 10.1016/s0140-6736(22)01988-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Nicholas M Selby
- Centre for Kidney Research and Innovation, Academic Unit of Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK; Department of Renal Medicine, Royal Derby Hospital, Derby, DE22 3DT, UK.
| | - Maarten W Taal
- Centre for Kidney Research and Innovation, Academic Unit of Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK; Department of Renal Medicine, Royal Derby Hospital, Derby, DE22 3DT, UK
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Bathish Y, Beiruti K, Safadi H, Nov AS, Bukovetzky E, Edelstein M, Halabi M, Israeli Z. Effects of hemodialysis with cooled dialysate on high-sensitivity cardiac troponin I and brain natriuretic peptide. Hemodial Int 2022; 26:533-539. [PMID: 35852035 PMCID: PMC9796558 DOI: 10.1111/hdi.13039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 06/26/2022] [Accepted: 07/05/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Hemodialysis (HD) triggers recurrent and cumulative ischemic insults to the brain and the heart. Cooled dialysate may have a protective effect on major organs and improve hemodynamic tolerability of dialysis. The aim of the study was to compare HD with cooled dialysate with routine dialysis in terms of hemodynamic stability and levels of high-sensitivity Troponin I (hs-TnI) and N-terminal pro b-type natriuretic peptide (NTproBNP) pre and postdialysis. METHODS The 45 patients were randomized into two groups. The first group received a 35.5°C dialysate first (hypothermic dialysis) and the second group a 36.5°C dialysate first (routine dialysis). Then groups crossed over, so each group received the alternate dialysate (self-controls) For each patient, the first sample was collected at the beginning of dialysis, and a second sample was taken at the end of dialysis. RESULTS AND CONCLUSION hs-TnI and NTproBNP increased after routine HD by 10.7 ng\ml (p < 0.001) and (12.0 pg/μl) (p < 0.001), respectively, and by -3.1 ng\ml (p = 0.25) and (4.3 pg/μl) (p < 0.001), respectively after hypothermic HD. Our study results showed a tendency towards less rise in hsTnI and NTproBNP during hypothermic HD (35.5°C) as compared to routine HD (36.5°C). Neither arm experienced statistically significant changes in blood pressure. Further studies in larger cohorts and long follow up are warranted in order to confirm that lower rise in (hs-TnI) and NTproBNP actually translate into lower clinical risk for cardiovascular events.
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Affiliation(s)
- Younes Bathish
- Nephrology and Hypertension Unit, Cardiology departmentZiv Medical CentreSafedIsrael,Azrieli Faculty of MedicineBar‐Ilan UniversitySafedIsrael
| | - Karine Beiruti
- Nephrology and Hypertension Unit, Cardiology departmentZiv Medical CentreSafedIsrael
| | - Hussein Safadi
- Nephrology and Hypertension Unit, Cardiology departmentZiv Medical CentreSafedIsrael
| | - Adi Sharabi Nov
- Nephrology and Hypertension Unit, Cardiology departmentZiv Medical CentreSafedIsrael,Statistical UnitTel‐Hai Academic CollegeTel‐HaiIsrael
| | - Elena Bukovetzky
- Nephrology and Hypertension Unit, Cardiology departmentZiv Medical CentreSafedIsrael
| | - Michael Edelstein
- Nephrology and Hypertension Unit, Cardiology departmentZiv Medical CentreSafedIsrael,Azrieli Faculty of MedicineBar‐Ilan UniversitySafedIsrael
| | - Majdi Halabi
- Nephrology and Hypertension Unit, Cardiology departmentZiv Medical CentreSafedIsrael,Azrieli Faculty of MedicineBar‐Ilan UniversitySafedIsrael
| | - Zeev Israeli
- Nephrology and Hypertension Unit, Cardiology departmentZiv Medical CentreSafedIsrael,Azrieli Faculty of MedicineBar‐Ilan UniversitySafedIsrael
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Rootjes PA, Chaara S, de Roij van Zuijdewijn CL, Nubé MJ, Wijngaarden G, Grooteman MP. High-Volume Hemodiafiltration and Cool Hemodialysis Have a Beneficial Effect on Intradialytic Hemodynamics: A Randomized Cross-Over Trial of Four Intermittent Dialysis Strategies. Kidney Int Rep 2022; 7:1980-1990. [PMID: 36090495 PMCID: PMC9459077 DOI: 10.1016/j.ekir.2022.06.021] [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: 06/13/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction Compared to standard hemodialysis (S-HD), postdilution hemodiafiltration (HDF) has been associated with improved survival. Methods To assess whether intradialytic hemodynamics may play a role in this respect, 40 chronic dialysis patients were cross-over randomized to S-HD (dialysate temperature [Td] 36.5 °C), cooled HD (C-HD; Td 35.5 °C), and HDF (low-volume [LV-HDF)] and high-volume [HV-HDF], both Td 36.5 °C, convection volume 15 liters, and at least 23 liters per session, respectively), each for 2 weeks. Blood pressure (BP) was measured every 15 minutes. The primary endpoint was the number of intradialytic hypotensive (IDH) episodes per session. IDH was defined as systolic BP (SBP) less than 90 mmHg for predialysis SBP less than 160 mmHg and less than 100 mmHg for predialysis SBP greater than or equal to 160 mmHg, independent of symptoms and interventions. A post hoc analysis on early-onset IDH was performed as well. Secondary endpoints included intradialytic courses of SBP, diastolic BP (DBP) and mean arterial pressure (MAP). Results During S-HD, IDH occurred 0.68 episodes per session, which was 3.2 and 2.5 times higher than during C-HD (0.21 per session, P < 0.0005) and HV-HDF (0.27 per session, P < 0.0005), respectively. Whereas the latter 2 strategies showed similar frequencies, HV-HDF differed significantly from LV-HDF (P = 0.02). A comparable trend was observed for early-onset IDH: S-HD (0.32 per session), C-HD (0.07 per session, P < 0.0005) and HV-HDF (0.10 per session, P = 0.001). SBP, DBP, and MAP declined during S-HD (−6.8, −5.2, −5.2 mmHg per session; P = 0.004, P < 0.0005, P = 0.002 respectively), which was markedly different from C-HD (P < 0.01). Conclusion Though C-HD and HV-HDF showed the lowest IDH frequency and the best intradialytic hemodynamic stability, all parameters were most disrupted in S-HD. Therefore, the survival benefit of HV-HDF over S-HD may be partly caused by a more beneficial intradialytic BP profile.
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Canaud B, Kooman J, Maierhofer A, Raimann J, Titze J, Kotanko P. Sodium First Approach, to Reset Our Mind for Improving Management of Sodium, Water, Volume and Pressure in Hemodialysis Patients, and to Reduce Cardiovascular Burden and Improve Outcomes. FRONTIERS IN NEPHROLOGY 2022; 2:935388. [PMID: 37675006 PMCID: PMC10479686 DOI: 10.3389/fneph.2022.935388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/07/2022] [Indexed: 09/08/2023]
Abstract
New physiologic findings related to sodium homeostasis and pathophysiologic associations require a new vision for sodium, fluid and blood pressure management in dialysis-dependent chronic kidney disease patients. The traditional dry weight probing approach that has prevailed for many years must be reviewed in light of these findings and enriched by availability of new tools for monitoring and handling sodium and water imbalances. A comprehensive and integrated approach is needed to improve further cardiac health in hemodialysis (HD) patients. Adequate management of sodium, water, volume and hemodynamic control of HD patients relies on a stepwise approach: the first entails assessment and monitoring of fluid status and relies on clinical judgement supported by specific tools that are online embedded in the HD machine or devices used offline; the second consists of acting on correcting fluid imbalance mainly through dialysis prescription (treatment time, active tools embedded on HD machine) but also on guidance related to diet and thirst management; the third consist of fine tuning treatment prescription to patient responses and tolerance with the support of innovative tools such as artificial intelligence and remote pervasive health trackers. It is time to come back to sodium and water imbalance as the root cause of the problem and not to act primarily on their consequences (fluid overload, hypertension) or organ damage (heart; atherosclerosis, brain). We know the problem and have the tools to assess and manage in a more precise way sodium and fluid in HD patients. We strongly call for a sodium first approach to reduce disease burden and improve cardiac health in dialysis-dependent chronic kidney disease patients.
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Affiliation(s)
- Bernard Canaud
- School of Medicine, Montpellier University, Montpellier, France
- Global Medical Office, Freseenius Medical Care (FMC)-France, Fresnes, France
| | - Jeroen Kooman
- Maastricht University Maastricht Medical Center (UMC), Maastricht University, Maastricht, Netherlands
| | - Andreas Maierhofer
- Global Research Development, Fresenius Medical Care (FMC) Deutschland GmbH, Bad Homburg, Germany
| | - Jochen Raimann
- Research Division, Renal Research Institute, New York, NY, United States
| | - Jens Titze
- Cardiovascular and Metabolic Disease Programme, Duke-National University Singapore (NUS) Medical School, Singapore, Singapore
| | - Peter Kotanko
- Research Division, Renal Research Institute, New York, NY, United States
- Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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15
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Canaud B, Kooman JP, Selby NM, Taal M, Maierhofer A, Kopperschmidt P, Francis S, Collins A, Kotanko P. Hidden risks associated with conventional short intermittent hemodialysis: A call for action to mitigate cardiovascular risk and morbidity. World J Nephrol 2022; 11:39-57. [PMID: 35433339 PMCID: PMC8968472 DOI: 10.5527/wjn.v11.i2.39] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 10/30/2021] [Accepted: 03/23/2022] [Indexed: 02/06/2023] Open
Abstract
The development of maintenance hemodialysis (HD) for end stage kidney disease patients is a success story that continues to save many lives. Nevertheless, intermittent renal replacement therapy is also a source of recurrent stress for patients. Conventional thrice weekly short HD is an imperfect treatment that only partially corrects uremic abnormalities, increases cardiovascular risk, and exacerbates disease burden. Altering cycles of fluid loading associated with cardiac stretching (interdialytic phase) and then fluid unloading (intradialytic phase) likely contribute to cardiac and vascular damage. This unphysiologic treatment profile combined with cyclic disturbances including osmotic and electrolytic shifts may contribute to morbidity in dialysis patients and augment the health burden of treatment. As such, HD patients are exposed to multiple stressors including cardiocirculatory, inflammatory, biologic, hypoxemic, and nutritional. This cascade of events can be termed the dialysis stress storm and sickness syndrome. Mitigating cardiovascular risk and morbidity associated with conventional intermittent HD appears to be a priority for improving patient experience and reducing disease burden. In this in-depth review, we summarize the hidden effects of intermittent HD therapy, and call for action to improve delivered HD and develop treatment schedules that are better tolerated and associated with fewer adverse effects.
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Affiliation(s)
- Bernard Canaud
- Global Medical Office, Fresenius Medical Care, Bad Homburg 61352, Germany
- Department of Nephrology, Montpellier University, Montpellier 34000, France
| | - Jeroen P Kooman
- Department of Internal Medicine, Maastricht University, Maastricht 6229 HX, Netherlands
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Derby DE22 3DT, United Kingdom
| | - Maarten Taal
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Derby DE22 3DT, United Kingdom
| | - Andreas Maierhofer
- Global Research Development, Fresenius Medical Care, Schweinfurt 97424, Germany
| | | | - Susan Francis
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham NG7 2RD, United Kingdom
| | - Allan Collins
- Global Medical Office, Fresenius Medical Care, Bad Homburg 61352, Germany
| | - Peter Kotanko
- Renal Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10065, United States
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Maki KC, Wilcox ML, Dicklin MR, Kakkar R, Davidson MH. Left ventricular mass regression, all-cause and cardiovascular mortality in chronic kidney disease: a meta-analysis. BMC Nephrol 2022; 23:34. [PMID: 35034619 PMCID: PMC8761349 DOI: 10.1186/s12882-022-02666-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 01/03/2022] [Indexed: 12/22/2022] Open
Abstract
Background Cardiovascular disease is an important driver of the increased mortality associated with chronic kidney disease (CKD). Higher left ventricular mass (LVM) predicts increased risk of adverse cardiovascular outcomes and total mortality, but previous reviews have shown no clear association between intervention-induced LVM change and all-cause or cardiovascular mortality in CKD. Methods The primary objective of this meta-analysis was to investigate whether treatment-induced reductions in LVM over periods ≥12 months were associated with all-cause mortality in patients with CKD. Cardiovascular mortality was investigated as a secondary outcome. Measures of association in the form of relative risks (RRs) with associated variability and precision (95% confidence intervals [CIs]) were extracted directly from each study, when reported, or were calculated based on the published data, if possible, and pooled RR estimates were determined. Results The meta-analysis included 42 trials with duration ≥12 months: 6 of erythropoietin stimulating agents treating to higher vs. lower hemoglobin targets, 10 of renin-angiotensin-aldosterone system inhibitors vs. placebo or another blood pressure lowering agent, 14 of modified hemodialysis regimens, and 12 of other types of interventions. All-cause mortality was reported in 121/2584 (4.86%) subjects in intervention groups and 168/2606 (6.45%) subjects in control groups. The pooled RR estimate of the 27 trials ≥12 months with ≥1 event in ≥1 group was 0.72 (95% CI 0.57 to 0.90, p = 0.005), with little heterogeneity across studies. Directionalities of the associations in intervention subgroups were the same. Sensitivity analyses of ≥6 months (34 trials), ≥9 months (29 trials), and >12 months (10 trials), and including studies with no events in either group, demonstrated similar risk reductions to the primary analysis. The point estimate for cardiovascular mortality was similar to all-cause mortality, but not statistically significant: RR 0.67, 95% CI 0.39 to 1.16. Conclusions These results suggest that LVM regression may be a useful surrogate marker for benefits of interventions intended to reduce mortality risk in patients with CKD. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02666-1.
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Affiliation(s)
- Kevin C Maki
- Department of Applied Health Science, Indiana University School of Public Health, 1025 E 7th St #111, Bloomington, IN, 47405, USA. .,Midwest Biomedical Research, Addison, IL, USA.
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Chronic Kidney Disease and Cognitive Impairment. J Stroke Cerebrovasc Dis 2021; 30:105529. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105529] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/05/2020] [Accepted: 12/01/2020] [Indexed: 12/21/2022] Open
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Kharche SR, Lemoine S, Tamasi T, Hur L, So A, McIntyre CW. Therapeutic Hypothermia Reduces Peritoneal Dialysis Induced Myocardial Blood Flow Heterogeneity and Arrhythmia. Front Med (Lausanne) 2021; 8:700824. [PMID: 34395480 PMCID: PMC8362929 DOI: 10.3389/fmed.2021.700824] [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: 04/26/2021] [Accepted: 06/30/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Moderate therapeutic hypothermia (TH) is a well-recognized cardio-protective strategy. The instillation of fluid into the peritoneum provides an opportunity to deliver moderate hypothermia as primary prevention against cardiovascular events. We aimed to to investigate both cardiac perfusion consequences (overall blood flow and detailed assessment of perfusion heterogeneity) and subsequently simulate the associated arrhythmic risk for patients undergoing peritoneal dialysis (PD) induced TH. Methods: Patients underwent high resolution myocardial perfusion scanning using high resolution 256 slice CT scanning, at rest and with adenosine stress. The first visit using the patient's usual PD regimen, on the second visit the same regime was utilized but with cooled peritoneal dialysate at 32°C. Myocardial blood flow (MBF) was quantified from generated perfusion maps, reconstructed in 3D. MBF heterogeneity was assessed by fractal dimension (FD) measurement on the 3D left ventricular reconstruction. Arrhythmogenicity was quantified from a sophisticated computational simulation using a multi-scale human 3D ventricle wedge electrophysiological computational model. Results: We studied 7 PD patients, mean age of 60 ± 7 and mean vintage dialysis of 23.6 ± 17.6 months. There were no significant different in overall segmental MBF between normothermic condition (NT) and TH. MBF heterogeneity was significantly decreased (-14%, p = 0.03) at rest and after stress (-14%, p = 0.03) when cooling was applied. Computational simulation showed that TH allowed a normalization of action potential, QT duration and T wave. Conclusion: TH-PD results in moderate hypothermia leading to a reduction in perfusion heterogeneity and simulated risk of non-terminating malignant ventricular arrhythmias.
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Affiliation(s)
- Sanjay R. Kharche
- Kidney Clinical Research Unit, Lawson's Health Research Institute, Victoria Hospital, London, ON, Canada
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Sandrine Lemoine
- Kidney Clinical Research Unit, Lawson's Health Research Institute, Victoria Hospital, London, ON, Canada
| | - Tanya Tamasi
- Kidney Clinical Research Unit, Lawson's Health Research Institute, Victoria Hospital, London, ON, Canada
| | - Lisa Hur
- Kidney Clinical Research Unit, Lawson's Health Research Institute, Victoria Hospital, London, ON, Canada
| | - Aaron So
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
- Imaging Program, Lawson Health Research Institute, London, ON, Canada
| | - Christopher W. McIntyre
- Kidney Clinical Research Unit, Lawson's Health Research Institute, Victoria Hospital, London, ON, Canada
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
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Rootjes PA, Nubé MJ, de Roij van Zuijdewijn CLM, Wijngaarden G, Grooteman MPC. Effect of various dialysis modalities on intradialytic hemodynamics, tissue injury and patient discomfort in chronic dialysis patients: design of a randomized cross-over study (HOLLANT). BMC Nephrol 2021; 22:131. [PMID: 33858390 PMCID: PMC8047527 DOI: 10.1186/s12882-021-02331-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/01/2021] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND From a recent meta-analysis it appeared that online post-dilution hemodiafiltration (HDF), especially with a high convection volume (HV-HDF), is associated with superior overall and cardiovascular survival, if compared to standard hemodialysis (HD). The mechanism(s) behind this effect, however, is (are) still unclear. In this respect, a lower incidence of intradialytic hypotension (IDH), and hence less tissue injury, may play a role. To address these items, the HOLLANT study was designed. METHODS HOLLANT is a Dutch multicentre randomized controlled cross-over trial. In total, 40 prevalent dialysis patients will be included and, after a run-in phase, exposed to standard HD, HD with cooled dialysate, low-volume HDF and high-volume HDF (Dialog iQ® machine) in a randomized fashion. The primary endpoint is an intradialytic nadir in systolic blood pressure (SBP) of < 90 and < 100 mmHg for patients with predialysis SBP < 159 and ≥ 160 mmHg, respectively. The main secondary outcomes are 1) intradialytic left ventricle (LV) chamber quantification and deformation, 2) intradialytic hemodynamic profile of SBP, diastolic blood pressure (DBP), mean arterial pressure (MAP) and pulse pressure (PP), 3) organ and tissue damage, such as the release of specific cellular components, and 4) patient reported symptoms and thermal perceptions during each modality. DISCUSSION The current trial is primarily designed to test the hypothesis that a lower incidence of intradialytic hypotension contributes to the superior survival of (HV)-HDF. A secondary objective of this investigation is the question whether changes in the intradialytic blood pressure profile correlate with organ dysfunction and tissue damage, and/or patient discomfort. TRIAL REGISTRATION Registered Report Identifier: NCT03249532 # ( ClinicalTrials.gov ). Date of registration: 2017/08/15.
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Affiliation(s)
- Paul A Rootjes
- Department of Nephrology and Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, VU University of Amsterdam, Amsterdam, The Netherlands
| | - Menso J Nubé
- Department of Nephrology and Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, VU University of Amsterdam, Amsterdam, The Netherlands
| | - Camiel L M de Roij van Zuijdewijn
- Department of Nephrology and Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, VU University of Amsterdam, Amsterdam, The Netherlands
| | - Gertrude Wijngaarden
- Department of Nephrology and Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, VU University of Amsterdam, Amsterdam, The Netherlands
| | - Muriel P C Grooteman
- Department of Nephrology and Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, VU University of Amsterdam, Amsterdam, The Netherlands.
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20
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Marants R, Qirjazi E, Lai KB, Szeto CC, Li PKT, Li F, Lee TY, McIntyre CW. Exploring the Link Between Hepatic Perfusion and Endotoxemia in Hemodialysis. Kidney Int Rep 2021; 6:1336-1345. [PMID: 34013112 PMCID: PMC8116762 DOI: 10.1016/j.ekir.2021.02.008] [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: 12/24/2020] [Revised: 01/25/2021] [Accepted: 02/01/2021] [Indexed: 01/18/2023] Open
Abstract
Introduction The liver receives gut-derived endotoxin via the portal vein, clearing it before it enters systemic circulation. Hemodialysis negatively impacts the perfusion and function of multiple organs systems. Dialysate cooling reduces hemodialysis-induced circulatory stress and protects organs from ischemic injury. This study examined how hemodialysis disrupts liver hemodynamics and function, its effect on endotoxemia, and the potential protective effect of dialysate cooling. Methods Fifteen patients were randomized to receive either standard (36.5°C dialysate temperature) or cooled (35.0°C) hemodialysis first in a two-visit crossover trial. We applied computed tomography (CT) liver perfusion imaging to patients before, 3 hours into and after each hemodialysis session. We measured hepatic perfusion and perfusion heterogeneity. Hepatic function was measured by indocyanine green (ICG) clearance. Endotoxin levels in blood throughout dialysis were also measured. Results During hemodialysis, overall liver perfusion did not significantly change, but portal vein perfusion trended towards increasing (P = 0.14) and perfusion heterogeneity significantly increased (P = 0.038). In addition, ICG clearance decreased significantly during hemodialysis (P = 0.016), and endotoxin levels trended towards increasing during hemodialysis (P = 0.15) and increased significantly after hemodialysis (P = 0.037). Applying dialysate cooling trended towards abrogating these changes but did not reach statistical significance compared to standard hemodialysis. Conclusion Hemodialysis redistributes liver perfusion, attenuates hepatic function, and results in endotoxemia. Higher endotoxin levels in end-stage renal disease (ESRD) patients may result from the combination of decreased hepatic clearance function and increasing fraction of liver perfusion coming from toxin-laden portal vein during hemodialysis. The protective potential of dialysate cooling should be explored further in future research studies.
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Affiliation(s)
- Raanan Marants
- Department of Medical Biophysics, Western University, London, Ontario, Canada.,Robarts Research Institute, Western University, London, Ontario, Canada
| | - Elena Qirjazi
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada.,Division of Nephrology, Alberta Health Sciences, Calgary, Alberta, Canada
| | - Ka-Bik Lai
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Cheuk-Chun Szeto
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Philip K T Li
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Fiona Li
- Department of Medical Biophysics, Western University, London, Ontario, Canada.,Robarts Research Institute, Western University, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| | - Ting-Yim Lee
- Department of Medical Biophysics, Western University, London, Ontario, Canada.,Robarts Research Institute, Western University, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| | - Christopher W McIntyre
- Department of Medical Biophysics, Western University, London, Ontario, Canada.,The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada.,Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada
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21
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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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22
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Rutherford E, Ireland S, Mangion K, Stewart GA, MacGregor MS, Roditi G, Woodward R, Gandy SJ, Houston JG, Jardine AG, Rauchhaus P, Witham MD, Mark PB, Struthers AD. A Randomized, Controlled Trial of the Effect of Allopurinol on Left Ventricular Mass Index in Hemodialysis Patients. Kidney Int Rep 2020; 6:146-155. [PMID: 33426394 PMCID: PMC7783562 DOI: 10.1016/j.ekir.2020.10.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/01/2020] [Accepted: 10/20/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction Increased left ventricular mass index (LVMI) is associated with mortality in end-stage renal disease. LVMI regression may improve outcomes. Allopurinol has reduced LVMI in randomized controlled trials in chronic kidney disease, diabetes, and ischemic heart disease. This study investigated whether allopurinol would regress LVMI in hemodialysis patients. Methods This was a randomized placebo-controlled double-blind multicenter trial funded by the British Heart Foundation (PG/12/72/29743). A total of 80 patients undergoing regular maintenance hemodialysis were recruited from NHS Tayside, NHS Greater Glasgow and Clyde and NHS Ayrshire and Arran in Scotland, UK. Participants were randomly assigned on a 1:1 ratio to 12 months of therapy with allopurinol 300 mg or placebo after each dialysis session. The primary outcome was change in LVMI, as assessed by cardiac magnetic resonance imaging (CMRI) at baseline and 12 months. Secondary outcomes were change in BP, flow-mediated dilation (FMD), augmentation indices (AIx), and pulse wave velocity (PWV). Results A total of 53 patients, with a mean age of 58 years, completed the study and had CMRI follow-up data for analysis. Allopurinol did not regress LVMI (change in LVMI: placebo +3.6 ± 10.4 g/m2; allopurinol: +1.6 ± 11 g/m2; P = 0.49). Allopurinol had no demonstrable effect on BP, FMD, AIx, or PWV. Conclusion Compared with placebo, treatment with allopurinol did not regress LVMI in this trial.
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Affiliation(s)
- Elaine Rutherford
- Institute of Cardiovascular and Medical Sciences, BHF Clinical Research Centre, University of Glasgow, UK.,Renal & Transplant Unit, Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Sheila Ireland
- Division of Molecular & Clinical Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - Kenneth Mangion
- Institute of Cardiovascular and Medical Sciences, BHF Clinical Research Centre, University of Glasgow, UK
| | | | - Mark S MacGregor
- Renal Unit, Crosshouse Hospital, NHS Ayrshire & Arran, Kilmarnock, UK
| | - Giles Roditi
- Institute of Cardiovascular and Medical Sciences, BHF Clinical Research Centre, University of Glasgow, UK.,Department of Radiology, Glasgow Royal Infirmary, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Rosemary Woodward
- Institute of Cardiovascular and Medical Sciences, BHF Clinical Research Centre, University of Glasgow, UK
| | - Stephen J Gandy
- Department of Radiology, Ninewells Hospital, NHS Tayside, Dundee, UK.,Medical Physics, Ninewells Hospital, NHS Tayside, Dundee, UK
| | | | - Alan G Jardine
- Institute of Cardiovascular and Medical Sciences, BHF Clinical Research Centre, University of Glasgow, UK.,Renal & Transplant Unit, Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Petra Rauchhaus
- Tayside Clinical Trials Unit, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - Miles D Witham
- NIHR Newcastle Biomedical Research Centre, Newcastle University and Newcastle upon Tyne Hospitals Trust, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, BHF Clinical Research Centre, University of Glasgow, UK.,Renal & Transplant Unit, Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Allan D Struthers
- Division of Molecular & Clinical Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
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23
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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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24
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Dasgupta I, Odudu A, Baharani J, Fergusson N, Griffiths H, Harrison J, Maruff P, Thomas GN, Woodhall G, Youseff S, Tadros G. Evaluation of the effect of Cooled HaEmodialysis on Cognitive function in patients suffering with end-stage KidnEy Disease (E-CHECKED): feasibility randomised control trial protocol. Trials 2020; 21:820. [PMID: 32998761 PMCID: PMC7526411 DOI: 10.1186/s13063-020-04725-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/03/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cognitive impairment is common in haemodialysis (HD) patients and is associated independently with depression and mortality. This association is poorly understood, and no intervention is proven to slow cognitive decline. There is evidence that cooler dialysis fluid (dialysate) may slow white matter changes in the brain, but no study has investigated the effect of cooler dialysate on cognition. This study addresses whether cooler dialysate can prevent the decline in cognition and improve quality of life (QOL) in HD patients. METHODS This is a multi-site prospective randomised, double-blinded feasibility trial. SETTING Four HD units in the UK. PARTICIPANTS AND INTERVENTIONS Ninety HD patients randomised (1:1) to standard care (dialysate temperature 36.5 °C) or intervention (dialysate temperature 35 °C) for 12 months. PRIMARY OUTCOME MEASURE Change in cognition using the Montreal Cognitive Assessment (MoCA). SECONDARY OUTCOME MEASURES Recruitment and attrition rates, reasons for non-recruitment, frequency of intradialytic hypotension, depressive symptom scores, patient and carers burden, a detailed computerised cognitive test and QOL assessments. ANALYSIS mixed method approach, utilising measurement of cognition, questionnaires, physiological measurements and semi-structured interviews. DISCUSSION The results of this feasibility trial will inform the design of a future adequately powered substantive trial investigating the effect of dialysate cooling on prevention and/or slowing in cognitive decline in patients undergoing haemodialysis using a computerised battery of neuro-cognitive tests. The main hypothesis that would be tested in this future trial is that patients treated with regular conventional haemodialysis will have a lesser decline in cognitive function and a better quality of life over 1 year by using cooler dialysis fluid at 35 °C, versus a standard dialysis fluid temperature of 36.5 °C. This also should reflect in improvements in their abilities for activities of daily living and therefore reduce carers' burden. If successful, the treatment could be universally applied at no extra cost. TRIAL REGISTRATION ClinicalTrials.gov NCT03645733 . Registered retrospectively on 24 August 2018.
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Affiliation(s)
- Indranil Dasgupta
- Renal Unit, Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, UK. .,Warwick Medical School, University of Warwick, Coventry, UK.
| | - Aghogho Odudu
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK.,Manchester University NHS Foundation Trust, Manchester, UK
| | - Jyoti Baharani
- Renal Unit, Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, UK
| | - Niall Fergusson
- Department of Care of the Elderly, Heartlands Hospital, Birmingham, UK
| | - Helen Griffiths
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - John Harrison
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | | | - G Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gavin Woodhall
- School of Neuropharmacology, Aston University, Birmingham, UK
| | | | - George Tadros
- Department of Old Age Psychiatry, Heartlands Hospital, Birmingham, UK.,Aston Medical School, Aston University, Birmingham, UK
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25
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Kanbay M, Ertuglu LA, Afsar B, Ozdogan E, Siriopol D, Covic A, Basile C, Ortiz A. An update review of intradialytic hypotension: concept, risk factors, clinical implications and management. Clin Kidney J 2020; 13:981-993. [PMID: 33391741 PMCID: PMC7769545 DOI: 10.1093/ckj/sfaa078] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 04/30/2020] [Indexed: 12/13/2022] Open
Abstract
Intradialytic hypotension (IDH) is a frequent and serious complication of chronic haemodialysis, linked to adverse long-term outcomes including increased cardiovascular and all-cause mortality. IDH is the end result of the interaction between ultrafiltration rate (UFR), cardiac output and arteriolar tone. Thus excessive ultrafiltration may decrease the cardiac output, especially when compensatory mechanisms (heart rate, myocardial contractility, vascular tone and splanchnic flow shifts) fail to be optimally recruited. The repeated disruption of end-organ perfusion in IDH may lead to various adverse clinical outcomes affecting the heart, central nervous system, kidney and gastrointestinal system. Potential interventions to decrease the incidence or severity of IDH include optimization of the dialysis prescription (cool dialysate, UFR, sodium profiling and high-flux haemofiltration), interventions during the dialysis session (midodrine, mannitol, food intake, intradialytic exercise and intermittent pneumatic compression of the lower limbs) and interventions in the interdialysis period (lower interdialytic weight gain and blood pressure–lowering drugs). However, the evidence base for many of these interventions is thin and optimal prevention and management of IDH awaits further clinical investigation. Developing a consensus definition of IDH will facilitate clinical research. We review the most recent findings on risk factors, pathophysiology and management of IDH and, based on this, we call for a new consensus definition of IDH based on clinical outcomes and define a roadmap for IDH research.
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Affiliation(s)
- Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Lale A Ertuglu
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Baris Afsar
- Department of Internal Medicine, Division of Nephrology, Suleyman Demirel University School of Medicine, Isparta, Turkey
| | - Elif Ozdogan
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Dimitrie Siriopol
- Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. PARHON' University Hospital, 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. PARHON' University Hospital, 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Carlo Basile
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy.,Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
| | - Alberto Ortiz
- Dialysis Unit, School of Medicine, IIS-Fundacion Jimenez Diaz, Universidad Autónoma de Madrid, Madrid, Spain
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26
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Roehm B, Gulati G, Weiner DE. Heart failure management in dialysis patients: Many treatment options with no clear evidence. Semin Dial 2020; 33:198-208. [PMID: 32282987 PMCID: PMC7597416 DOI: 10.1111/sdi.12878] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure with reduced ejection fraction (HFrEF) impacts approximately 20% of dialysis patients and is associated with high mortality rates. Key issues discussed in this review of HFrEF management in dialysis include dialysis modality choice, vascular access, dialysate composition, pharmacological therapies, and strategies to reduce sudden cardiac death, including the use of cardiac devices. Peritoneal dialysis and more frequent or longer duration of hemodialysis may be better tolerated due to slower ultrafiltration rates, leading to less intradialytic hypotension and better volume control; dialysate cooling and higher dialysate calcium may also have benefits. While high-quality evidence exists for many drug classes in the non-dialysis population, dialysis patients were excluded from major trials, and only limited data exist for many medications in kidney failure patients. Despite limited evidence, beta blocker and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use is common in dialysis. Similarly, devices such as implantable cardiac defibrillators (ICDs) and cardiac resynchronization therapy that have proven benefits in non-dialysis HFrEF patients have not consistently been beneficial in the limited dialysis studies. The use of leadless pacemakers and subcutaneous ICDs can mitigate future hemodialysis access limitations. Additional research is critical to address knowledge gaps in treating maintenance dialysis patients with HFrEF.
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Affiliation(s)
- Bethany Roehm
- William B. Schwartz MD Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Gaurav Gulati
- Cardiovascular Center, Division of Cardiology, Tufts Medical Center, Boston, MA
| | - Daniel E. Weiner
- William B. Schwartz MD Division of Nephrology, Tufts Medical Center, Boston, MA
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27
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Flythe JE, Chang TI, Gallagher MP, Lindley E, Madero M, Sarafidis PA, Unruh ML, Wang AYM, Weiner DE, Cheung M, Jadoul M, Winkelmayer WC, Polkinghorne KR. Blood pressure and volume management in dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2020; 97:861-876. [PMID: 32278617 PMCID: PMC7215236 DOI: 10.1016/j.kint.2020.01.046] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/05/2019] [Accepted: 01/08/2020] [Indexed: 02/07/2023]
Abstract
Blood pressure (BP) and volume control are critical components of dialysis care and have substantial impacts on patient symptoms, quality of life, and cardiovascular complications. Yet, developing consensus best practices for BP and volume control have been challenging, given the absence of objective measures of extracellular volume status and the lack of high-quality evidence for many therapeutic interventions. In February of 2019, Kidney Disease: Improving Global Outcomes (KDIGO) held a Controversies Conference titled Blood Pressure and Volume Management in Dialysis to assess the current state of knowledge related to BP and volume management and identify opportunities to improve clinical and patient-reported outcomes among individuals receiving maintenance dialysis. Four major topics were addressed: BP measurement, BP targets, and pharmacologic management of suboptimal BP; dialysis prescriptions as they relate to BP and volume; extracellular volume assessment and management with a focus on technology-based solutions; and volume-related patient symptoms and experiences. The overarching theme resulting from presentations and discussions was that managing BP and volume in dialysis involves weighing multiple clinical factors and risk considerations as well as patient lifestyle and preferences, all within a narrow therapeutic window for avoiding acute or chronic volume-related complications. Striking this challenging balance requires individualizing the dialysis prescription by incorporating comorbid health conditions, treatment hemodynamic patterns, clinical judgment, and patient preferences into decision-making, all within local resource constraints.
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Affiliation(s)
- Jennifer E Flythe
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina, USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA.
| | - Tara I Chang
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Martin P Gallagher
- George Institute for Global Health, Renal and Metabolic Division, Camperdown, Australia; Concord Repatriation General Hospital, Department of Renal Medicine, Sydney, Australia
| | - Elizabeth Lindley
- Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Magdalena Madero
- Department of Medicine, Division of Nephrology, National Institute of Cardiology "Ignacio Chávez", Mexico City, Mexico
| | - Pantelis A Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Mark L Unruh
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Daniel E Weiner
- William B. Schwartz Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Michel Jadoul
- Department of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Health, Clayton, Melbourne, Australia; Department of Medicine, Monash University, Clayton, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Prahan, Melbourne, Australia.
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28
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Park S, Paredes W, Custodio M, Goel N, Sapkota D, Bandla A, Lynn RI, Reddy SM, Hostetter TH, Abramowitz MK. Intradialytic acid-base changes and organic anion production during high versus low bicarbonate hemodialysis. Am J Physiol Renal Physiol 2020; 318:F1418-F1429. [PMID: 32308019 DOI: 10.1152/ajprenal.00036.2020] [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] [Indexed: 01/06/2023] Open
Abstract
The use of high dialysate bicarbonate for hemodialysis in end-stage renal disease is associated with increased mortality, but potential physiological mediators are poorly understood. Alkalinization due to high dialysate bicarbonate may stimulate organic acid generation, which could lead to poor outcomes. Using measurements of β-hydroxybutyrate (BHB) and lactate, we quantified organic anion (OA) balance in two single-arm studies comparing high and low bicarbonate prescriptions. In study 1 (n = 10), patients became alkalemic using 37 meq/L dialysate bicarbonate; in contrast, with the use of 27 meq/L dialysate, net bicarbonate loss occurred and blood bicarbonate decreased. Total OA losses were not higher with 37 meq/L dialysate bicarbonate (50.9 vs. 49.1 meq using 27 meq/L, P = 0.66); serum BHB increased in both treatments similarly (P = 0.27); and blood lactate was only slightly higher with the use of 37 meq/L dialysate (P = 0.048), differing by 0.2 meq/L at the end of hemodialysis. In study 2 (n = 7), patients achieved steady state on two bicarbonate prescriptions: they were significantly more acidemic when dialyzed against a 30 meq/L bicarbonate dialysate compared with 35 meq/L and, as in study 1, became alkalemic when dialyzed against the higher bicarbonate dialysate. OA losses were similar to those in study 1 and again did not differ between treatments (38.9 vs. 43.5 meq, P = 0.42). Finally, free fatty acid levels increased throughout hemodialysis and correlated with the change in serum BHB (r = 0.81, P < 0.001), implicating upregulation of lipolysis as the mechanism for increased ketone production. In conclusion, lowering dialysate bicarbonate does not meaningfully reduce organic acid generation during hemodialysis or modify organic anion losses into dialysate.
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Affiliation(s)
- Sarah Park
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - William Paredes
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Matthew Custodio
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Narender Goel
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Deepak Sapkota
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Anusha Bandla
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Robert I Lynn
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York.,Kidney Medical Associates, Bronx, New York
| | | | - Thomas H Hostetter
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Matthew K Abramowitz
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York.,Institute for Aging Research, Albert Einstein College of Medicine, Bronx, New York.,Diabetes Research Center, Albert Einstein College of Medicine, Bronx, New York.,Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine, Bronx, New York
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29
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Penny JD, Salerno FR, Brar R, Garcia E, Rossum K, McIntyre CW, Bohm CJ. Intradialytic exercise preconditioning: an exploratory study on the effect on myocardial stunning. Nephrol Dial Transplant 2020; 34:1917-1923. [PMID: 30590580 DOI: 10.1093/ndt/gfy376] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 10/31/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Exercise preconditioning provides immediate protection against cardiac ischemia in clinical/preclinical studies in subjects without chronic kidney disease. In individuals requiring renal replacement therapy, hemodialysis (HD) results in significant circulatory stress, causing acute ischemia with resultant recurrent and cumulative cardiac injury (myocardial stunning). Intradialytic exercise (IDE) has been utilized to improve functional status in individuals receiving HD. The objective of this study was to explore the role of IDE as a preconditioning intervention and assess its effect on HD-induced myocardial stunning. METHODS We performed a single-center cross-sectional exploratory study in adults on chronic HD participating in a clinical IDE program. HD-induced cardiac stunning was evaluated over two HD sessions within the same week: a control visit (no exercise) and an exposure visit (usual intradialytic cycling). Echocardiography was performed at the same three time points for each visit. Longitudinal strain values for 12 left ventricular segments were generated using speckle-tracking software to assess the presence of HD-induced regional wall motion abnormalities (RWMAs), defined as a ≥20% reduction in strain; two or more RWMAs represent myocardial stunning. RESULTS A total of 19 patients were analyzed (mean age 57.2 ± 11.8 years, median dialysis vintage 3.8 years). The mean number of RWMAs during the control visit was 4.5 ± 2.6, falling to 3.6 ± 2.7 when incorporating IDE (a reduction of -0.95 ± 2.9; P = 0.17). At peak HD stress, the mean number of RWMAs was 5.8 ± 2.7 in the control visit versus 4.0 ± 1.8 during the exposure visit (a reduction of -1.8 ± 2.8; P = 0.01). CONCLUSION We demonstrated for the first time that IDE is associated with a significant reduction in HD-induced acute cardiac injury.
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Affiliation(s)
- Jarrin D Penny
- Lilibeth Caberto Kidney Clinical Research Unit, University of Western Ontario, London, Ontario, Canada.,Department of Medical Biophysics, University of Western Ontario, London, Ontario, Canada
| | - Fabio R Salerno
- Lilibeth Caberto Kidney Clinical Research Unit, University of Western Ontario, London, Ontario, Canada.,Department of Medical Biophysics, University of Western Ontario, London, Ontario, Canada
| | - Ranveer Brar
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Eric Garcia
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Manitoba Renal Program, Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada
| | - Krista Rossum
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Christopher W McIntyre
- Lilibeth Caberto Kidney Clinical Research Unit, University of Western Ontario, London, Ontario, Canada.,Department of Medical Biophysics, University of Western Ontario, London, Ontario, Canada.,Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| | - Clara J Bohm
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada.,Manitoba Renal Program, Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada
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30
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Guler HS, Tulunay Kaya C, Kumru G, Kosku H, Ozyuncu N, Sengul S, Kutlay S. Acute stunning effect of hemodialysis on myocardial performance: A three-dimensional speckle tracking echocardiographic study. Artif Organs 2020; 44:1081-1089. [PMID: 32279336 DOI: 10.1111/aor.13698] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 03/28/2020] [Accepted: 04/03/2020] [Indexed: 11/30/2022]
Abstract
The effects of acute changes during hemodialysis (HD) on the myocardium are not yet known. The invention of three-dimensional speckle tracking echocardiography (3DSTE) has offered clinicians a new method to assess the movements of ventricular segments simultaneously in three spatial directions. The aim of this study was to evaluate the effect of first weekly standard HD process on the left ventricle (LV) and right ventricle (RV) global and regional myocardial function in patients with normal left ventricle ejection fraction using 3DSTE-derived indices. Patients (n=38) receiving maintenance HD in our clinic who have no known cardiovascular disease are examined just before and after a HD session using 3DSTE. Demographic and comorbidity data, renal replacement treatment characteristics, and laboratory test results are recorded. 3DSTE analysis is performed to calculate the LV global longitudinal, circumferential area and radial peak systolic strain, as well as RV septum and free-wall longitudinal strain and fractional area change. Patients are aged 52.8 ± 13.6 years and 52.6% of them are male. Mean dialysis duration is 56 months. The LV strain values of the patients changed markedly before and after HD (GLS: -14.2 ± 5.2, -11.1 ± 4.6 [P < .001], GCS: -14.8 ± 4.2, -12.4 ± 5.28 [P < .009]; GRS: 41.5 ± 16, 33.3 ± 16.5 [P = .003]; AREA -24.7 ± 7.2, -20.1 ± 7.6 [P = .001], respectively). We could not demonstrate any improvement in RV strain values before or after HD. LV strain values are positively correlated with blood pressure variability during the dialysis sessions. LV function is preserved better after HD in patients on beta or calcium channel blocker therapy compared to those who do not use these agents (P < .001, P < .01, respectively). HD treatment results in deterioration in all LV strain directions but not in RV. Strain assessment may improve vascular risk stratification of patients on chronic HD.
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Affiliation(s)
- Hasan Selim Guler
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - Cansin Tulunay Kaya
- Department of Cardiology, Ankara University School of Medicine, Ankara, Turkey
| | - Gizem Kumru
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - Hakan Kosku
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - Nil Ozyuncu
- Department of Cardiology, Ankara University School of Medicine, Ankara, Turkey
| | - Sule Sengul
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - Sim Kutlay
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
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Al-Jaishi AA, McIntyre CW, Sontrop JM, Dixon SN, Anderson S, Bagga A, Benjamin D, Berry D, Blake PG, Chambers L, Chan PCK, Delbrouck N, Devereaux PJ, Ferreira-Divino LF, Goluch R, Gregor L, Grimshaw JM, Hanson G, Iliescu E, Jain AK, Lok CE, Mustafa RA, Nathoo B, Nesrallah GE, Oliver MJ, Pandeya S, Parmar MS, Perkins D, Presseau J, Rabin E, Sasal J, Shulman T, Sood MM, Steele A, Tam P, Tascona D, Wadehra D, Wald R, Walsh M, Watson P, Wodchis W, Zager P, Zwarenstein M, Garg AX. Major Outcomes With Personalized Dialysate TEMPerature (MyTEMP): Rationale and Design of a Pragmatic, Registry-Based, Cluster Randomized Controlled Trial. Can J Kidney Health Dis 2020; 7:2054358119887988. [PMID: 32076569 PMCID: PMC7003172 DOI: 10.1177/2054358119887988] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/23/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Small randomized trials demonstrated that a lower compared with higher dialysate temperature reduced the average drop in intradialytic blood pressure. Some observational studies demonstrated that a lower compared with higher dialysate temperature was associated with a lower risk of all-cause mortality and cardiovascular mortality. There is now the need for a large randomized trial that compares the effect of a low vs high dialysate temperature on major cardiovascular outcomes. OBJECTIVE The purpose of this study is to test the effect of outpatient hemodialysis centers randomized to (1) a personalized temperature-reduced dialysate protocol or (2) a standard-temperature dialysate protocol for 4 years on cardiovascular-related death and hospitalizations. DESIGN The design of the study is a pragmatic, registry-based, open-label, cluster randomized controlled trial. SETTING Hemodialysis centers in Ontario, Canada, were randomized on February 1, 2017, for a trial start date of April 3, 2017, and end date of March 31, 2021. PARTICIPANTS In total, 84 hemodialysis centers will care for approximately 15 500 patients and provide over 4 million dialysis sessions over a 4-year follow-up. INTERVENTION Hemodialysis centers were randomized (1:1) to provide (1) a personalized temperature-reduced dialysate protocol or (2) a standard-temperature dialysate protocol of 36.5°C. For the personalized protocol, nurses set the dialysate temperature between 0.5°C and 0.9°C below the patient's predialysis body temperature for each dialysis session, to a minimum dialysate temperature of 35.5°C. PRIMARY OUTCOME A composite of cardiovascular-related death or major cardiovascular-related hospitalization (a hospital admission with myocardial infarction, congestive heart failure, or ischemic stroke) captured in Ontario health care administrative databases. PLANNED PRIMARY ANALYSIS The primary analysis will follow an intent-to-treat approach. The hazard ratio of time-to-first event will be estimated from a Cox model. Within-center correlation will be considered using a robust sandwich estimator. Observation time will be censored on the trial end date or when patients die from a noncardiovascular event. TRIAL REGISTRATION www.clinicaltrials.gov; identifier: NCT02628366.
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Affiliation(s)
- Ahmed A. Al-Jaishi
- London Health Sciences Centre, ON, Canada
- ICES, ON, Canada
- McMaster University, Hamilton, ON, Canada
| | | | - Jessica M. Sontrop
- London Health Sciences Centre, ON, Canada
- Western University, London, ON, Canada
| | - Stephanie N. Dixon
- London Health Sciences Centre, ON, Canada
- ICES, ON, Canada
- Western University, London, ON, Canada
| | | | | | | | - David Berry
- Sault Area Hospital, Sault Ste. Marie, ON, Canada
| | - Peter G. Blake
- London Health Sciences Centre, ON, Canada
- Western University, London, ON, Canada
| | | | | | | | | | | | | | | | - Jeremy M. Grimshaw
- Ottawa Hospital Research Institute, ON, Canada
- University of Ottawa, ON, Canada
| | | | | | - Arsh K. Jain
- London Health Sciences Centre, ON, Canada
- ICES, ON, Canada
- Western University, London, ON, Canada
| | | | - Reem A. Mustafa
- McMaster University, Hamilton, ON, Canada
- University of Kansas Medical Center, Kansas City, USA
| | | | | | - Matthew J. Oliver
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- University of Toronto, ON, Canada
| | | | | | | | - Justin Presseau
- Ottawa Hospital Research Institute, ON, Canada
- University of Ottawa, ON, Canada
| | - Eli Rabin
- Niagara Health System, St. Catharines, ON, Canada
| | | | | | - Manish M. Sood
- ICES, ON, Canada
- Ottawa Hospital Research Institute, ON, Canada
- University of Ottawa, ON, Canada
| | | | - Paul Tam
- Scarborough Health Network, ON, Canada
| | | | | | - Ron Wald
- ICES, ON, Canada
- University of Toronto, ON, Canada
- St. Michael’s Hospital, Toronto, ON, Canada
| | - Michael Walsh
- McMaster University, Hamilton, ON, Canada
- St. Joseph’s Healthcare, Hamilton, ON, Canada
| | - Paul Watson
- Thunder Bay Regional Health Sciences Centre, ON, Canada
| | | | | | | | - Amit X. Garg
- London Health Sciences Centre, ON, Canada
- ICES, ON, Canada
- McMaster University, Hamilton, ON, Canada
- Western University, London, ON, Canada
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Burden and challenges of heart failure in patients with chronic kidney disease. A call to action. Nefrologia 2019; 40:223-236. [PMID: 31901373 DOI: 10.1016/j.nefro.2019.10.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 10/16/2019] [Indexed: 01/16/2023] Open
Abstract
Patients with the dual burden of chronic kidney disease (CKD) and chronic congestive heart failure (HF) experience unacceptably high rates of symptom load, hospitalization, and mortality. Currently, concerted efforts to identify, prevent and treat HF in CKD patients are lacking at the institutional level, with emphasis still being placed on individual specialty views on this topic. The authors of this review paper endorse the need for a dedicated cardiorenal interdisciplinary team that includes nephrologists and renal nurses and jointly manages appropriate clinical interventions across the inpatient and outpatient settings. There is a critical need for guidelines and best clinical practice models from major cardiology and nephrology professional societies, as well as for research funding in both specialties to focus on the needs of future therapies for HF in CKD patients. The implementation of cross-specialty educational programs across all levels in cardiology and nephrology will help train future specialists and nurses who have the ability to diagnose, treat, and prevent HF in CKD patients in a precise, clinically effective, and cost-favorable manner.
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Sars B, van der Sande FM, Kooman JP. Intradialytic Hypotension: Mechanisms and Outcome. Blood Purif 2019; 49:158-167. [PMID: 31851975 DOI: 10.1159/000503776] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 09/28/2019] [Indexed: 12/14/2022]
Abstract
Intradialytic hypotension (IDH) occurs in approximately 10-12% of treatments. Whereas several definitions for IDH are available, a nadir systolic blood pressure carries the strongest relation with outcome. Whereas the relation between IDH may partly be based on patient characteristics, it is likely that also impaired organ perfusion leading to permanent damage, plays a role in this relationship. The pathogenesis of IDH is multifactorial and is based on a combination of a decline in blood volume (BV) and impaired vascular resistance at a background of a reduced cardiovascular reserve. Measurements of absolute BV based on an on-line dilution method appear more promising than relative BV measurements in the prediction of IDH. Also, feedback treatments in which ultrafiltration rate is automatically adjusted based on changes in relative BV have not yet resulted in improvement. Frequent assessment of dry weight, attempting to reduce interdialytic weight gain and prescribing more frequent or longer dialysis treatments may aid in preventing IDH. The impaired vascular response can be improved using isothermic or cool dialysis treatment which has also been associated with a reduction in end organ damage, although their effect on mortality has not yet been assessed. For the future, identification of vulnerable patients based on artificial intelligence and on-line assessment of markers of organ perfusion may aid in individualizing treatment prescription, which will always remain dependent on the clinical context of the patient.
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Affiliation(s)
- Benedict Sars
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Frank M van der Sande
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jeroen P Kooman
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands,
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Hart A, Johansen KL. Cardiovascular protection and mounting evidence for the benefits of intradialytic exercise. Nephrol Dial Transplant 2019; 34:1816-1818. [PMID: 30830221 PMCID: PMC6826164 DOI: 10.1093/ndt/gfz038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 12/30/2022] Open
Affiliation(s)
- Allyson Hart
- Division of Nephrology, Hennepin Healthcare System, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Kirsten L Johansen
- Division of Nephrology, Hennepin Healthcare System, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Tsujimoto Y, Tsujimoto H, Nakata Y, Kataoka Y, Kimachi M, Shimizu S, Ikenoue T, Fukuma S, Yamamoto Y, Fukuhara S. Dialysate temperature reduction for intradialytic hypotension for people with chronic kidney disease requiring haemodialysis. Cochrane Database Syst Rev 2019; 7:CD012598. [PMID: 31273758 PMCID: PMC6609546 DOI: 10.1002/14651858.cd012598.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Intradialytic hypotension (IDH) is a common complication of haemodialysis (HD), and a risk factor of cardiovascular morbidity and death. Several clinical studies suggested that reduction of dialysate temperature, such as fixed reduction of dialysate temperature or isothermal dialysate using a biofeedback system, might improve the IDH rate. OBJECTIVES This review aimed to evaluate the benefits and harms of dialysate temperature reduction for IDH among patients with chronic kidney disease requiring HD, compared with standard dialysate temperature. SEARCH METHODS We searched Cochrane Kidney and Transplant's Specialised Register up to 14 May 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs), cross-over RCTs, cluster RCTs and quasi-RCTs were included in the review. DATA COLLECTION AND ANALYSIS Two authors independently extracted information including participants, interventions, outcomes, methods of the study, and risks of bias. We used a random-effects model to perform quantitative synthesis of the evidence. We assessed the risks of bias for each study using the Cochrane 'Risk of bias' tool. We assessed the certainty of evidence using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). MAIN RESULTS We included 25 studies (712 participants). Three studies were parallel RCTs and the others were cross-over RCTs. Nineteen studies compared fixed reduction of dialysate temperature (below 36°C) and standard dialysate temperature (37°C to 37.5°C). Most studies were of unclear or high risk of bias. Compared with standard dialysate, it is uncertain whether fixed reduction of dialysate temperature improves IDH rate (8 studies, 153 participants: rate ratio 0.52, 95% CI 0.34 to 0.80; very low certainty evidence); however, it might increase the discomfort rate compared with standard dialysate (4 studies, 161 participants: rate ratio 8.31, 95% CI 1.86 to 37.12; very low certainty evidence). There were no reported dropouts due to adverse events. No study reported death, acute coronary syndrome or stroke.Three studies compared isothermal dialysate and thermoneutral dialysate. Isothermal dialysate might improve the IDH rate compared with thermoneutral dialysate (2 studies, 133 participants: rate ratio 0.68, 95% CI 0.60 to 0.76; I2 = 0%; very low certainty evidence). There were no reports of discomfort rate (1 study) or dropouts due to adverse events (2 studies). No study reported death, acute coronary syndrome or stroke. AUTHORS' CONCLUSIONS Reduction of dialysate temperature may prevent IDH, but the conclusion is uncertain. Larger studies that measure important outcomes for HD patients are required to assess the effect of reduction of dialysate temperature. Six ongoing studies may provide much-needed high quality evidence in the future.
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Affiliation(s)
- Yasushi Tsujimoto
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
| | - Hiraku Tsujimoto
- Hyogo Prefectural Amagasaki General Medical CenterHospital Care Research UnitHigashi‐Naniwa‐Cho 2‐17‐77AmagasakiHyogoHyogoJapan606‐8550
| | - Yukihiko Nakata
- Shimane UniversityDepartment of Mathematics1060 Nishikawatsu choMatsue690‐8504Japan
| | - Yuki Kataoka
- Hyogo Prefectural Amagasaki General Medical CenterDepartment of Respiratory Medicine2‐17‐77, Higashi‐Naniwa‐ChoAmagasakiHyogoJapan660‐8550
| | - Miho Kimachi
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
| | - Sayaka Shimizu
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
| | - Tatsuyoshi Ikenoue
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
| | - Shingo Fukuma
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
| | - Yosuke Yamamoto
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
| | - Shunichi Fukuhara
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
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Abstract
PURPOSE OF REVIEW Intra-dialytic hypotension (IDH) remains a significant problem for patients undergoing chronic haemodialysis. IDH causes symptoms that degrade patients' experience, compromises dialysis delivery and is strongly associated with adverse patient outcomes. Greater understanding of the link between IDH and dialysis-induced ischaemia in heart and brain has characterized mechanistic pathways, with repeated episodes of ischaemia resulting in organ dysfunction. This review provides updates from published evidence over the last 2 years across the range of potential interventions for IDH. RECENT FINDINGS A literature search was undertaken to identify articles published in peer review journals between January 2016 and April 2018 using terms 'intradialytic hypotension,' 'haemodynamic instability,' 'ESRF,' 'renal replacement therapy,' 'dialysis' in Medline and EMBASE and identified 58 references from which 15 articles were included in this review. Interventions included: cooling the dialysate; sodium profiling; convective therapies; strategies to minimize inter-dialytic weight gain (IDWG) and improve accuracy of target weight assessment; prescribing of antihypertensive medications; and carnitine supplementation. SUMMARY IDH remains a significant clinical problem. Recent evidence from the last 2 years does not support any major changes to current practice, with cooling of the dialysate and reduction of IDWG remaining cornerstones of management.
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Slessarev M, Salerno F, Ball IM, McIntyre CW. Continuous renal replacement therapy is associated with acute cardiac stunning in critically ill patients. Hemodial Int 2019; 23:325-332. [PMID: 31094070 DOI: 10.1111/hdi.12760] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 04/04/2019] [Accepted: 04/14/2019] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Intermittent renal replacement therapy induces cardiac stunning in chronic hemodialysis and acute kidney injury (AKI) patients. In chronic hemodialysis, recurrent stunning contributes to heart failure and cardiac death, with ultrafiltration and intradialytic hypotension being the principal determinants of this injury. Continuous renal replacement therapy (CRRT), with its lower ultrafiltration rates and improved hemodynamic profile, should protect against cardiac stunning in AKI. The objective of this study was to assess whether CRRT is associated with cardiac stunning in critically ill patients with AKI. METHODS We prospectively measured cardiac function using global and segmental longitudinal left ventricular strain using transthoracic echocardiography in 11 critically ill patients who were started on CRRT for AKI. We compared measurements at 4, 8, and 24 hours to baseline immediately prior to initiation of CRRT, with each patient serving as their own control. We also recorded blood pressure, heart rate, dose of vasoactive medications and intensive care unit mortality. FINDINGS Ten of 11 patients developed new regional cardiac stunning, with 8/11 within 4 hours of starting CRRT, despite stable hemodynamics. The number of affected left ventricular segments varied from 1 to 11 (out of 12). The stunning occurred both in patients with preserved and impaired baseline cardiac function, and 7/11 patients died in the intensive care unit. DISCUSSION Initiation of CRRT in critically ill patients with AKI is associated with cardiac stunning despite stable hemodynamics. This mechanism may explain lack of clinical benefit of CRRT over intermittent modalities and warrants further investigation to improve cardiovascular outcomes in critically ill patients with AKI.
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Affiliation(s)
- Marat Slessarev
- Department of Medicine, Western University, London, Ontario, Canada.,Department of Medical Biophysics, Western University, London, Ontario, Canada
| | - Fabio Salerno
- Department of Medicine, Western University, London, Ontario, Canada
| | - Ian M Ball
- Department of Medicine, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Christopher W McIntyre
- Department of Medicine, Western University, London, Ontario, Canada.,Department of Medical Biophysics, Western University, London, Ontario, Canada
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Marants R, Qirjazi E, Grant CJ, Lee TY, McIntyre CW. Renal Perfusion during Hemodialysis: Intradialytic Blood Flow Decline and Effects of Dialysate Cooling. J Am Soc Nephrol 2019; 30:1086-1095. [PMID: 31053638 DOI: 10.1681/asn.2018121194] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/05/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Residual renal function (RRF) confers survival in patients with ESRD but declines after initiating hemodialysis. Previous research shows that dialysate cooling reduces hemodialysis-induced circulatory stress and protects the brain and heart from ischemic injury. Whether hemodialysis-induced circulatory stress affects renal perfusion, and if it can be ameliorated with dialysate cooling to potentially reduce RRF loss, is unknown. METHODS We used renal computed tomography perfusion imaging to scan 29 patients undergoing continuous dialysis under standard (36.5°C dialysate temperature) conditions; we also scanned another 15 patients under both standard and cooled (35.0°C) conditions. Imaging was performed immediately before, 3 hours into, and 15 minutes after hemodialysis sessions. We used perfusion maps to quantify renal perfusion. To provide a reference to another organ vulnerable to hemodialysis-induced ischemic injury, we also used echocardiography to assess intradialytic myocardial stunning. RESULTS During standard hemodialysis, renal perfusion decreased 18.4% (P<0.005) and correlated with myocardial injury (r=-0.33; P<0.05). During sessions with dialysis cooling, patients experienced a 10.6% decrease in perfusion (not significantly different from the decline with standard hemodialysis), and ten of the 15 patients showed improved or no effect on myocardial stunning. CONCLUSIONS This study shows an acute decrease in renal perfusion during hemodialysis, a first step toward pathophysiologic characterization of hemodialysis-mediated RRF decline. Dialysate cooling ameliorated this decline but this effect did not reach statistical significance. Further study is needed to explore the potential of dialysate cooling as a therapeutic approach to slow RRF decline.
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Affiliation(s)
- Raanan Marants
- Department of Medical Biophysics, Western University, London, Canada.,Robarts Research Institute, Western University, London, Canada
| | - Elena Qirjazi
- The Lilibeth Caberto Kidney Clinical Research Unit and
| | - Claire J Grant
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Ting-Yim Lee
- Department of Medical Biophysics, Western University, London, Canada.,Robarts Research Institute, Western University, London, Canada.,Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Christopher W McIntyre
- Department of Medical Biophysics, Western University, London, Canada; .,The Lilibeth Caberto Kidney Clinical Research Unit and.,Lawson Health Research Institute, London Health Sciences Centre, London, Canada.,Division of Nephrology, London Health Sciences Centre, London, Canada; and
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House AA, Wanner C, Sarnak MJ, Piña IL, McIntyre CW, Komenda P, Kasiske BL, Deswal A, deFilippi CR, Cleland JGF, Anker SD, Herzog CA, Cheung M, Wheeler DC, Winkelmayer WC, McCullough PA. Heart failure in chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2019; 95:1304-1317. [PMID: 31053387 DOI: 10.1016/j.kint.2019.02.022] [Citation(s) in RCA: 215] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/13/2019] [Accepted: 02/21/2019] [Indexed: 12/24/2022]
Abstract
The incidence and prevalence of heart failure (HF) and chronic kidney disease (CKD) are increasing, and as such a better understanding of the interface between both conditions is imperative for developing optimal strategies for their detection, prevention, diagnosis, and management. To this end, Kidney Disease: Improving Global Outcomes (KDIGO) convened an international, multidisciplinary Controversies Conference titled Heart Failure in CKD. Breakout group discussions included (i) HF with preserved ejection fraction (HFpEF) and nondialysis CKD, (ii) HF with reduced ejection fraction (HFrEF) and nondialysis CKD, (iii) HFpEF and dialysis-dependent CKD, (iv) HFrEF and dialysis-dependent CKD, and (v) HF in kidney transplant patients. The questions that formed the basis of discussions are available on the KDIGO website http://kdigo.org/conferences/heart-failure-in-ckd/, and the deliberations from the conference are summarized here.
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Affiliation(s)
- Andrew A House
- Division of Nephrology, Department of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada.
| | - Christoph Wanner
- Department of Medicine, Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Mark J Sarnak
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ileana L Piña
- Division of Cardiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Christopher W McIntyre
- Division of Nephrology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Paul Komenda
- Department of Internal Medicine, Section of Nephrology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Medicine, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Community Health Sciences, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Anita Deswal
- Section of Cardiology, Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, USA; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, UK; National Heart and Lung Institute, Imperial College, London, UK
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Berlin, Germany; Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK, German Centre for Cardiovascular Research), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA; Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, USA
| | | | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Peter A McCullough
- Department of Internal Medicine, Division of Cardiology, Baylor University Medical Center, Dallas, Texas, USA; Department of Internal Medicine, Division of Cardiology, Baylor Heart and Vascular Institute, Dallas, Texas, USA.
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Dasgupta I, Thomas GN, Clarke J, Sitch A, Martin J, Bieber B, Hecking M, Karaboyas A, Pisoni R, Port F, Robinson B, Rayner H. Associations between Hemodialysis Facility Practices to Manage Fluid Volume and Intradialytic Hypotension and Patient Outcomes. Clin J Am Soc Nephrol 2019; 14:385-393. [PMID: 30723164 PMCID: PMC6419273 DOI: 10.2215/cjn.08240718] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 12/14/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND OBJECTIVES Fluid overload and intradialytic hypotension are associated with cardiovascular events and mortality in patients on hemodialysis. We investigated associations between hemodialysis facility practices related to fluid volume and intradialytic hypotension and patient outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data were analyzed from 10,250 patients in 273 facilities across 12 countries, from phase 4 of the Dialysis Outcomes and Practice Patterns Study (DOPPS; 2009-2012). Cox regression models (shared frailty) were used to estimate associations between facility practices reported by medical directors in response to the DOPPS Medical Directors Survey and all-cause and cardiovascular mortality and hospitalization, and cardiovascular events, adjusting for country, age, sex, dialysis vintage, predialysis systolic BP, cardiovascular comorbidities, diabetes, body mass index, smoking, residual kidney function, dialysis adequacy, and vascular access type. RESULTS Of ten facility practices tested (chosen a priori), having a protocol that specifies how often to assess dry weight in most patients was associated with lower all-cause (hazard ratio [HR], 0.78; 99% confidence interval [99% CI], 0.64 to 0.94) and cardiovascular mortality (HR, 0.72; 99% CI, 0.55 to 0.95). Routine orthostatic BP measurement to assess dry weight was associated with lower all-cause hospitalization (HR, 0.86; 99% CI, 0.77 to 0.97) and cardiovascular events (HR, 0.85; 99% CI, 0.73 to 0.98). Routine use of lower dialysate temperature to limit or prevent intradialytic hypotension was associated with lower cardiovascular mortality (HR, 0.76; 99% CI, 0.58 to 0.98). Routine use of an online volume indicator to assess dry weight was associated with higher all-cause hospitalization (HR, 1.19; 99% CI, 1.02 to 1.38). Routine use of sodium modeling/profiling to limit or prevent intradialytic hypotension was associated with higher all-cause mortality (HR, 1.36; 99% CI, 1.14 to 1.63), cardiovascular mortality (HR, 1.34; 99% CI, 1.04 to 1.73), and cardiovascular events (HR, 1.21; 99% CI, 1.03 to 1.43). CONCLUSIONS Hemodialysis facility practices relating to the management of fluid volume and intradialytic hypotension are associated with patient outcomes.
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Affiliation(s)
- Indranil Dasgupta
- Department of Renal Medicine, Heartlands Hospital, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - G. Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Joanne Clarke
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Alice Sitch
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- National Institute for Health Research, Birmingham Biomedical Research Centre, University Hospitals Birmingham National Health Service Foundation Trust and University of Birmingham, Birmingham, UK
| | - James Martin
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Manfred Hecking
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Angelo Karaboyas
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Ronald Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Friedrich Port
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Bruce Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Hugh Rayner
- Department of Renal Medicine, Heartlands Hospital, Birmingham, UK
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41
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Kanda E, Tsuruta Y, Kikuchi K, Masakane I. Use of vasopressor for dialysis-related hypotension is a risk factor for death in hemodialysis patients: Nationwide cohort study. Sci Rep 2019; 9:3362. [PMID: 30833633 PMCID: PMC6399330 DOI: 10.1038/s41598-019-39908-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 02/05/2019] [Indexed: 01/16/2023] Open
Abstract
Because hypotension during hemodialysis (HD) makes continuation of HD difficult and is associated with mortality, pressor approaches are necessary for patients with hypotension. However, the relationships between the pressor approaches and the risk of death have not been clarified yet. We analyzed data from a nationwide prospective cohort study of the Japanese Society for Dialysis Therapy Renal Data Registry (n = 29,309). The outcome was all-cause one-year death. The association between the use of pressor approaches and the outcome was examined using Cox proportional hazards models adjusted for baseline characteristics, propensity score matched analysis and Bayesian networks. The background features of the patients were as follows: male, 59.6%; average age, 64.5 ± 12.5 years; and patients with diabetes mellitus, 31.5%. The pressor group showed a higher risk of the outcome than the control group [adjusted hazard ratio (aHR) 1.33 (95% CI: 1.21, 1.47), p = 0.0001]. Propensity score matched analysis also showed that the matched-pressor group had a higher risk of the outcome than the matched-control group [aHR 1.30 (95% CI: 1.17, 1.45), p = 0.0001]. Moreover, the Bayesian network showed a direct causal relationship from the use of pressor approaches to the outcome. The use of oral vasopressors [aHR 1.20 (95% CI: 1.07, 1.35), p = 0.0018], intravenous injection of vasopressors [aHR 1.54 (95% CI: 1.32, 1.79), p = 0.0001] and normal saline [aHR 1.18 (95% CI: 1.05, 1.33), p = 0.0066] were associated with a high risk of the outcome. In conclusion, this study showed that the use of pressor approaches during HD may be an independent risk factor for death.
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Affiliation(s)
- Eiichiro Kanda
- Medical Science, Kawasaki Medical School, Okayama, Japan.
| | | | | | - Ikuto Masakane
- Department of Nephrology, Honcho Yabuki Clinic, Yamagata, Japan
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42
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Pathogenesis of cerebral edema in patients with acute renal and liver failure and the role of the nephrologist in the management. Curr Opin Nephrol Hypertens 2019; 27:289-297. [PMID: 29771702 DOI: 10.1097/mnh.0000000000000425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Acute liver failure (ALF) is a severe and complex illness and one of the most daunting conditions managed in the ICU. Because the renal care is intertwined with multiple disciplines, the aim of this review is to examine the multifactorial pathogenesis of cerebral edema in ALF, covering basic established facts as well as recent advances in our understanding of this condition. RECENT FINDINGS Acetaminophen remains the most common cause of ALF in the United States and many European countries. The incidence of cerebral edema continues to decline owing to earlier detection and improved management. The pathogenesis of cerebral edema has shifted from a unifactorial hypothesis involving the failed liver to a multifactorial cause. Recent evidence focuses on the role of liver-induced systemic inflammation and its implication in increasing the permeability of the blood-brain barrier. The role of brain aquaporin-4 in mediating water entry into the brain is further clarified. Controversial data regarding the effect of acute kidney injury on the brain emerged. Hyponatremia has been shown to worsen the outcome in acute-on-chronic liver failure patients thus validating findings in animal models. New evidence shed the light on the changes in serum osmolality and potential tissue hypoxia during continuous renal replacement therapy and points to the risks associated with such therapy. SUMMARY ALF is a severe systemic illness that is potentially reversible. Understanding the interaction between the multiple failed organs will help the nephrologist provide well tolerated and efficient care.
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43
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Veerappan I, Thiruvenkadam G, Abraham G, Dasari BR, Rajagopal A. Effect of Isothermic Dialysis on Intradialytic Hypertension. Indian J Nephrol 2019; 29:317-323. [PMID: 31571737 PMCID: PMC6755930 DOI: 10.4103/ijn.ijn_113_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The primary outcome was incidence of intradialytic hypertension (IDH) during standard and cooler isothermic dialysate temperatures. Two pair of haemodialysis sessions were done at 37°C (SHD) and at isothermic temperature (IHD). All the four dialysis were done on the same time of the day to negate the changes due to circadian variation in body temperature. Axillary and tympanic temperatures were measured before start of the dialysis and dialysis temperature was adjusted as per axillary temperature. Sixty patients were enrolled and completed the study. The mean delivered dialysate temperature in the intervention group was 36.5 ± 0.2 achieving a 0.5 ± 0.2°C between-group separation. The incidence of IDH and intradialytic hypotension while on SHD and IHD were 79/120 (66%) vs 44/120 (37%), odds ratio (OR) 3.3, 95% confidence interval (CI) (1.96–5.65) and 45/120 (38%) vs 14/120 (12%), OR 4.5, 95% CI (2.3–8.7), respectively. The 4 h time averaged mean systolic blood pressure (SBP) at IHD and SHD were 154 ± 1.7 and 157.2 ± 1.1 mmHg, respectively, the mean difference in SBP being −3.4 mmHg to −3.1 mmHg, 95% CI, P < 0.001. The standard deviation, a measure of BP variability was lower at IHD than at SHD (P < 0.001). In a subgroup analysis during IHD there was a significant reduction of both SBP and diastolic BP during the entire duration of dialysis in 35 out of 60 patients (systolic 4 h mean 154.96 ± 2.22 vs 164.32 ± 1.99 mmHg), (diastolic 4 h mean 79.24 ± 0.82 vs 82.54 ± 0.68 mmHg) – (rANOVA for systolic and diastolic <0.001). This phenomenon of cooler dialysis causing reduction of BP was reproduced in the same group of patients when the IHD was repeated another time (systolic 4 h mean 157.95 ± 1.88 vs 160.65 ± 1.47), (diastolic 4 h mean 79.27 ± 0.74 vs 82.03 ± 1.07) rANOVA for systolic and diastolic <0.001. The incidence of IDH can be reduced significantly by reducing the dialysate temperature to patients' body temperature. Hypertension during dialysis is related to heat gain during dialysis.
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Affiliation(s)
- I Veerappan
- Department of Nephrology, KG Hospital and Postgraduate Institute, Coimbatore, Tamil Nadu, India
| | - G Thiruvenkadam
- Department of General Medicine, Kavery Hospital, Trichy, Tamil Nadu, India
| | - G Abraham
- Department of Nephrology, Madras Medical Mission, Chennai, Tamil Nadu, India.,Department of Nephrology and General Medicine, Pondicherry Institute of Medical Sciences, Puducherry, Tamil Nadu, India
| | - B R Dasari
- Department of Physiology, Pondicherry Institute of Medical Sciences, Puducherry, Tamil Nadu, India
| | - A Rajagopal
- Department of Statistics, Indian Statistical Institute, Coimbatore, Tamil Nadu, India
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44
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Bullen A, Rifkin D, Trzebinska D. Individualized Cool Dialysate as an Effective Therapy for Intradialytic Hypotension and Hemodialysis Patients' Perception. Ther Apher Dial 2018; 23:145-152. [PMID: 30226300 DOI: 10.1111/1744-9987.12761] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/17/2018] [Accepted: 09/14/2018] [Indexed: 01/22/2023]
Abstract
Intradialytic hypotension (IDH) is the most common dialytic complication. Recurrent episodes of ischemia secondary to hemodynamic instability are associated with cardiomyopathy, increased risk of thrombosis of arteriovenous fistula, decreased quality of life, and increased mortality. Cool dialysate may be an effective approach to reducing intradialytic hypotension by promoting peripheral vasoconstriction. Most studies to date are small and do not employ individualized cool dialysates (ICD). The study consisted of standard and cool phases, with patients as their own controls. During the standard phase, participants underwent hemodialysis (HD) at their usual dialysate temperature at 37°C for six consecutive hemodialysis sessions. In the cool phase, the dialysate temperature was set at the core baseline temperature -0.5°C for six more sessions. We compared hemodynamic parameters during the standard and cool phases. A total of 93 participants were included. The number of IDH episodes during the standard and cool phases were 3.3 ± 2.8 and 2.0 ± 2.2 per patient respectively (P < 0.001). Other hemodynamic parameters including lowest intradialytic mean arterial pressure were significantly increased with ICD. We found that there was a high baseline rate of feeling cold among all participants and it increased after the implementation of ICD; however, the dropout rate was approximately 5%. ICD is an effective tool to decrease the frequency of IDH in the HD population and we provide a pragmatic, real-world approach to implement this technique.
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Affiliation(s)
- Alexander Bullen
- Division of Nephrology, Department of Medicine, School of Medicine, University of California-San Diego, La Jolla, CA, USA
| | - Dena Rifkin
- Division of Nephrology, Department of Medicine, School of Medicine, University of California-San Diego, La Jolla, CA, USA.,Division of Preventive Medicine, Department of Family Medicine and Public Health, School of Medicine, University of California-San Diego, La Jolla, CA, USA
| | - Danuta Trzebinska
- Division of Nephrology, Department of Medicine, School of Medicine, University of California-San Diego, La Jolla, CA, USA
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45
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Extracorporeal organ support (ECOS) in critical illness and acute kidney injury: from native to artificial organ crosstalk. Intensive Care Med 2018; 44:1447-1459. [DOI: 10.1007/s00134-018-5329-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 07/18/2018] [Indexed: 12/11/2022]
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46
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Kooman JP, Katzarski K, van der Sande FM, Leunissen KM, Kotanko P. Hemodialysis: A model for extreme physiology in a vulnerable patient population. Semin Dial 2018; 31:500-506. [DOI: 10.1111/sdi.12704] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jeroen P. Kooman
- Division of Nephrology; Department of Internal Medicine; Maastricht University Medical Center; Maastricht The Netherlands
| | - Krassimir Katzarski
- Dialysis Unit Solna Gate; Diaverum AB; and Division of Renal Medicine; Department of Clinical Science; Intervention and Technology; Karolinska Institutet; Stockholm Sweden
| | - Frank M. van der Sande
- Division of Nephrology; Department of Internal Medicine; Maastricht University Medical Center; Maastricht The Netherlands
| | - Karel M. Leunissen
- Division of Nephrology; Department of Internal Medicine; Maastricht University Medical Center; Maastricht The Netherlands
| | - Peter Kotanko
- Renal Research Institute; New York NY USA
- Icahn School of Medicine at Mount Sinai; New York NY USA
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47
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Rutherford E, Mark PB. What happens to the heart in chronic kidney disease? J R Coll Physicians Edinb 2018; 47:76-82. [PMID: 28569289 DOI: 10.4997/jrcpe.2017.117] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Cardiovascular disease is common in patients with chronic kidney disease. The increased risk of cardiovascular disease seen in this population is attributable to both traditional and novel vascular risk factors. Risk of sudden cardiac or arrhythmogenic death is greatly exaggerated in chronic kidney disease, particularly in patients with end stage renal disease where the risk is roughly 20 times that of the general population. The reasons for this increased risk are not entirely understood and while atherosclerosis is accelerated in the presence of chronic kidney disease, premature myocardial infarction does not solely account for the excess risk. Recent work demonstrates that the structure and function of the heart starts to alter early in chronic kidney disease, independent of other risk factors. The implications of cardiac remodelling and hypertrophy may predispose chronic kidney disease patients to heart failure, arrhythmia and myocardial ischaemia. Further research is needed to minimise cardiovascular risk associated with structural and functional heart disease associated with chronic kidney disease.
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Affiliation(s)
- E Rutherford
- P Mark, BHF Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK,
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48
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Hemodynamic Instability during Dialysis: The Potential Role of Intradialytic Exercise. BIOMED RESEARCH INTERNATIONAL 2018; 2018:8276912. [PMID: 29682559 PMCID: PMC5848102 DOI: 10.1155/2018/8276912] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 01/24/2018] [Indexed: 12/11/2022]
Abstract
Acute haemodynamic instability is a natural consequence of disordered cardiovascular physiology during haemodialysis (HD). Prevalence of intradialytic hypotension (IDH) can be as high as 20–30%, contributing to subclinical, transient myocardial ischemia. In the long term, this results in progressive, maladaptive cardiac remodeling and impairment of left ventricular function. This is thought to be a major contributor to increased cardiovascular mortality in end stage renal disease (ESRD). Medical strategies to acutely attenuate haemodynamic instability during HD are suboptimal. Whilst a programme of intradialytic exercise training appears to facilitate numerous chronic adaptations, little is known of the acute physiological response to this type of exercise. In particular, the potential for intradialytic exercise to acutely stabilise cardiovascular hemodynamics, thus preventing IDH and myocardial ischemia, has not been explored. This narrative review aims to summarise the characteristics and causes of acute haemodynamic instability during HD, with an overview of current medical therapies to treat IDH. Moreover, we discuss the acute physiological response to intradialytic exercise with a view to determining the potential for this nonmedical intervention to stabilise cardiovascular haemodynamics during HD, improve coronary perfusion, and reduce cardiovascular morbidity and mortality in ESRD.
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49
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Douvris A, Malhi G, Hiremath S, McIntyre L, Silver SA, Bagshaw SM, Wald R, Ronco C, Sikora L, Weber C, Clark EG. Interventions to prevent hemodynamic instability during renal replacement therapy in critically ill patients: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:41. [PMID: 29467008 PMCID: PMC5822560 DOI: 10.1186/s13054-018-1965-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 01/24/2018] [Indexed: 01/09/2023]
Abstract
Background Hemodynamic instability related to renal replacement therapy (HIRRT) may increase the risk of death and limit renal recovery. Studies in end-stage renal disease populations on maintenance hemodialysis suggest that some renal replacement therapy (RRT)-related interventions (e.g., cool dialysate) may reduce the occurrence of HIRRT, but less is known about interventions to prevent HIRRT in critically ill patients receiving RRT for acute kidney injury (AKI). We sought to evaluate the effectiveness of RRT-related interventions for reducing HIRRT in such patients across RRT modalities. Methods A systematic review of publications was undertaken using MEDLINE, MEDLINE in Process, EMBASE, and Cochrane’s Central Registry for Randomized Controlled Trials (RCTs). Studies that assessed any intervention’s effect on HIRRT (the primary outcome) in critically ill patients with AKI were included. HIRRT was variably defined according to each study’s definition. Two reviewers independently screened abstracts, identified articles for inclusion, extracted data, and evaluated study quality using validated assessment tools. Results Five RCTs and four observational studies were included (n = 9; 623 patients in total). Studies were small, and the quality was mostly low. Interventions included dialysate sodium modeling (n = 3), ultrafiltration profiling (n = 2), blood volume (n = 2) and temperature control (n = 3), duration of RRT (n = 1), and slow blood flow rate at initiation (n = 1). Some studies applied more than one strategy simultaneously (n = 5). Interventions shown to reduce HIRRT from three studies (two RCTs and one observational study) included higher dialysate sodium concentration, lower dialysate temperature, variable ultrafiltration rates, or a combination of strategies. Interventions not found to have an effect included blood volume and temperature control, extended duration of intermittent RRT, and slower blood flow rates during continuous RRT initiation. How HIRRT was defined and its frequency of occurrence varied widely across studies, including those involving the same RRT modality. Pooled analysis was not possible due to study heterogeneity. Conclusions Small clinical studies suggest that higher dialysate sodium, lower temperature, individualized ultrafiltration rates, or a combination of these strategies may reduce the risk of HIRRT. Overall, for all RRT modalities, there is a paucity of high-quality data regarding interventions to reduce the occurrence of HIRRT in critically ill patients. Electronic supplementary material The online version of this article (10.1186/s13054-018-1965-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adrianna Douvris
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Gurpreet Malhi
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Lauralyn McIntyre
- Division of Critical Care, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada.,Centre for Transfusion Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Samuel A Silver
- Division of Nephrology, Queen's University, Kingston, ON, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael's Hospital, Toronto, ON, Canada
| | - Claudio Ronco
- International Renal Research Institute and Department of Nephrology, St. Bortolo Hospital, Vicenza, Italy
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, ON, Canada
| | - Catherine Weber
- Division of Nephrology, McGill University, Montreal, Quebec, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada. .,The Ottawa Hospital - Riverside Campus, 1967 Riverside Drive, Ottawa, ON, K1H 7W9, Canada.
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50
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Dasgupta I, Patel M, Mohammed N, Baharani J, Subramanian T, Thomas GN, Tadros G. Cognitive Function Declines Significantly during Haemodialysis in a Majority of Patients: A Call for Further Research. Blood Purif 2018; 45:347-355. [PMID: 29455207 DOI: 10.1159/000485961] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 12/01/2017] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Cognitive impairment (CI) is very common condition that occurs in haemodialysis patients and it is associated with reduced functional capacity and mortality. We assessed the change in cognitive function during haemodialysis and associated risk factors. METHODS All patients ≥50 years, on haemodialysis for ≥3 months, no dementia from 2 dialysis centres were selected. Cognition was assessed before and after a haemodialysis session using parallel versions of the Montreal Cognitive Assessment (MOCA) tool. Multiple regression was used to examine potential confounders. RESULTS Eight-two patients completed both tests - median age 73 (52-91) years, 59% male, dialysis vintage 41 (3-88) months. Sixty-two (76%) had CI at baseline. Cognition declined over dialysis (MOCA 21 ± 4.8 to 19.1 ± 4.1, p < 0.001) and domains affected were attention, language, abstraction and delayed recall. Age and dialysis vintage were independently associated with decline. CONCLUSION Cognitive function declines over a haemodialysis session and this has significant clinical implications over health literacy, self-management and tasks like driving. More research is needed to find the cause for this decline in cognition.
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Affiliation(s)
- Indranil Dasgupta
- Department of Nephrology, Heartlands Hospital, Birmingham, United Kingdom
| | - Mitesh Patel
- Department of Psychiatry, Heartlands Hospital, Birmingham, United Kingdom
| | - Nuredin Mohammed
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Jyoti Baharani
- Department of Nephrology, Heartlands Hospital, Birmingham, United Kingdom
| | | | - G Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - George Tadros
- Department of Psychiatry, Heartlands Hospital, Birmingham, United Kingdom.,Aston Medical School, Aston University, Birmingham, United Kingdom
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