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Xiang Y, Ma G, Yang Q, Cao M, Xu W, Li L, Yang Q. External validation of the prediction model of intradialytic hypotension: a multicenter prospective cohort study. Ren Fail 2024; 46:2322031. [PMID: 38466674 DOI: 10.1080/0886022x.2024.2322031] [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: 08/31/2023] [Accepted: 02/17/2024] [Indexed: 03/13/2024] Open
Abstract
OBJECTIVE Intradialytic hypotension (IDH) is a common and serious complication in patients with Maintenance Hemodialysis (MHD). The purpose of this study is to externally verify three IDH risk prediction models recently developed by Ma et al. and recalibrate, update and present the optimal model to improve the accuracy and applicability of the model in clinical environment. METHODS A multicenter prospective cohort study of patients from 11 hemodialysis centers in Sichuan Province, China, was conducted using convenience sampling from March 2022 to July 2022, with a follow-up period of 1 month. Model performance was assessed by: (1) Discrimination: Evaluated through the computation of the Area Under Curve (AUC) and its corresponding 95% confidence intervals. (2) Calibration: scrutinized through visual inspection of the calibration plot and utilization of the Brier score. (3) The incremental value of risk prediction and the utility of updating the model were gauged using NRI (Net Reclassification Improvement) and IDI (Integrated Discrimination Improvement). Decision Curve Analysis (DCA) was employed to evaluate the clinical benefit of updating the model. RESULTS The final cohort comprised 2235 individuals undergoing maintenance hemodialysis, exhibiting a 14.6% occurrence rate of IDH. The externally validated Area Under the Curve (AUC) values for the three original prediction models were 0.746 (95% CI: 0.718 to 0.775), 0.709 (95% CI: 0.679 to 0.739), and 0.735 (95% CI: 0.706 to 0.764) respectively. Conversely, the AUC value for the recalibrated and updated columnar plot model reached 0.817 (95% CI: 0.791 to 0.842), accompanied by a Brier score of 0.081. Furthermore, Decision Curve Analysis (DCA) exhibited a net benefit within the threshold probability range of 15.2% to 87.1%. CONCLUSION Externally validated, recalibrated, updated, and presented IDH prediction models may serve as a valuable instrument for evaluating IDH risk in clinical practice. Furthermore, they hold the potential to guide clinical providers in discerning individuals at risk and facilitating judicious clinical intervention decisions.
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Affiliation(s)
- Yuhe Xiang
- School of Nursing, Chengdu Medical College, Chengdu, China
| | - Guoting Ma
- Health Management Center, Sichuan Tai Kang Hospital, Chengdu, China
| | - Qin Yang
- School of Nursing, Chengdu Medical College, Chengdu, China
| | - Min Cao
- Department of Orthopedics, Sichuan second traditional Chinese medicine hospital, Chengdu, China
| | - Wenbin Xu
- School of Nursing, Chengdu Medical College, Chengdu, China
| | - Lin Li
- School of Nursing, Chengdu Medical College, Chengdu, China
| | - Qian Yang
- School of Nursing, Chengdu Medical College, Chengdu, China
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Shen B, Luo F, Yuan N, Yin J, Chai Y, Sun L, Zhang L, Luo C. Outcomes and complications of hemodialysis in patients with renal cancer following bilateral nephrectomy. Open Med (Wars) 2024; 19:20241009. [PMID: 39221033 PMCID: PMC11365463 DOI: 10.1515/med-2024-1009] [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: 11/15/2023] [Revised: 06/21/2024] [Accepted: 07/08/2024] [Indexed: 09/04/2024] Open
Abstract
Objectives The management of patients undergoing bilateral nephrectomy for renal cancer presents significant challenges, particularly in addressing hypotension, anemia, and tumor recurrence during hemodialysis. Case presentation A patient diagnosed with renal clear cell carcinoma in 2009 was followed until his demise in June 2022, with detailed documentation of symptoms, signs, laboratory results, diagnosis, and treatment. In the presented case, post-nephrectomy, the patient experienced frequent hypotension and anemia during dialysis, improving with erythropoietin-stimulating agents and subsequently with rosuvastatin. Later, multiple metastases were detected, correlating with normalized blood pressure and hemoglobin. Literature review A literature search up to September 2023 was also conducted, gathering data on hypotension, anemia, and tumor recurrence post-nephrectomy. Literature analysis of six cases revealed a 100% tumor recurrence rate in elderly patients (>50 years). Conclusion Treatment of anemia in bilateral nephrectomy patients warrants consideration of medication-induced tumor recurrence, highlighting early kidney transplantation to avoid adverse reactions like hypotension.
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Affiliation(s)
- Bing Shen
- Qingdao University, Qingdao266071, P.R. China
- The Affiliated Hospital of Qingdao University, Qingdao266000, Shandong, P.R. China
| | - Feng Luo
- The Affiliated Hospital of Qingdao University, Qingdao266000, Shandong, P.R. China
| | - Nan Yuan
- The Affiliated Hospital of Qingdao University, Qingdao266000, Shandong, P.R. China
| | - Jiaming Yin
- The Affiliated Hospital of Qingdao University, Qingdao266000, Shandong, P.R. China
| | - Yalin Chai
- The Affiliated Hospital of Qingdao University, Qingdao266000, Shandong, P.R. China
| | - Lijie Sun
- The Affiliated Hospital of Qingdao University, Qingdao266000, Shandong, P.R. China
| | - Lin Zhang
- The Affiliated Hospital of Qingdao University, Qingdao266000, Shandong, P.R. China
| | - Congjuan Luo
- The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Shinan District, Qingdao266000, Shandong, P.R. China
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Wang Z, Li H, Sun L, Liu B, Gu X. Efficacy and safety of ultrafiltration combined with haemodialysis in patients with uraemia who cannot tolerate dialysis because of hypotension. Acta Cardiol 2024; 79:599-604. [PMID: 37906024 DOI: 10.1080/00015385.2023.2268426] [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: 07/11/2023] [Revised: 09/11/2023] [Accepted: 10/02/2023] [Indexed: 11/02/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of ultrafiltration (UF) combined with haemodialysis (HD) sequential therapy in patients with intradialytic hypotension (IDH) and water retention. METHODS A total of 53 uraemia patients with IDH who could not tolerate dehydration and significant water and sodium retention (net weight gain of more than 4 kg) were randomly divided into control group (28 cases) and treatment group (25 cases). After adjusting dialysis parameters (blood pump speed and excessive filtration), HD was tried again in the control group, and UF combined with HD was given sequential treatment in the treatment group. Outcome measures included efficacy measures (duration of treatment, total water removal, weight loss, dyspnoea score and left ventricular ejection fraction) and safety measures (heart rate, blood pressure, IDH incidence, bleeding and thromboembolic events). RESULTS In terms of efficacy indicators, In the sequential treatment group, the duration of treatment (740 ± 168 min vs. 380 ± 94 min, p < 0.05), total water removal (5280 ± 968 mL vs. 2980 ± 765 mL, p < 0.05) and the weight loss (2756 ± 537 g vs. 1421 ± 362 g, p < 0.05) was significantly higher than that of control group. Postoperative dyspnoea score (1.92 ± 0.400 vs. 3.32 ± 0.476, p < 0.05), left ventricular ejection fraction (LVEF; 49.25 ± 3.76 vs. 56.46 ± 4.42, p < 0.05) was significantly improved compared with that before treatment, and the difference was statistically significant. In control group, dyspnoea score (1.89 ± 0.416 vs. 1.82 ± 0.390, p > 0.05) and left ventricular ejection fraction (49.04 ± 6.72 vs. 48.61 ± 7.12, p > 0.05) were slightly improved after treatment, but there was no statistical significance. In terms of safety indicators, patients in the control group were prone to significant blood pressure fluctuation during treatment, and the incidence of IDH was significantly higher than that in the treatment group (75% vs. 0%, p < 0.01), the difference was statistically significant, while the other safety indicators (heart rate change, bleeding and thromboembolic events) showed no statistically significant difference between the two groups. CONCLUSIONS Compared with conventional HD, UF combined with HD can safely and effectively reduce water retention in patients with uraemia while avoiding IDH.
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Affiliation(s)
- Zhen Wang
- Medical College of Yangzhou University, Yangzhou, PR China
- Department of Cardiology, Friendliness Hospital Yangzhou, Yangzhou, PR China
| | - Hongxiao Li
- Department of Cardiovascular Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, PR China
| | - Lei Sun
- Medical College of Yangzhou University, Yangzhou, PR China
- Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou, PR China
| | - Bin Liu
- Department of Cardiology, Friendliness Hospital Yangzhou, Yangzhou, PR China
| | - Xiang Gu
- Medical College of Yangzhou University, Yangzhou, PR China
- Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou, PR China
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Roy A, Cumberland MJ, O'Shea C, Holmes A, Kalla M, Gehmlich K, Geberhiwot T, Steeds RP. Arrhythmogenesis in Fabry Disease. Curr Cardiol Rep 2024; 26:545-560. [PMID: 38607539 PMCID: PMC11199244 DOI: 10.1007/s11886-024-02053-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE OF REVIEW Fabry Disease (FD) is a rare lysosomal storage disorder characterised by multiorgan accumulation of glycosphingolipid due to deficiency in the enzyme α-galactosidase A. Cardiac sphingolipid accumulation triggers various types of arrhythmias, predominantly ventricular arrhythmia, bradyarrhythmia, and atrial fibrillation. Arrhythmia is likely the primary contributor to FD mortality with sudden cardiac death, the most frequent cardiac mode of death. Traditionally FD was seen as a storage cardiomyopathy triggering left ventricular hypertrophy, diastolic dysfunction, and ultimately, systolic dysfunction in advanced disease. The purpose of this review is to outline the current evidence exploring novel mechanisms underlying the arrhythmia substrate. RECENT FINDINGS There is growing evidence that FD cardiomyopathy is a primary arrhythmic disease with each stage of cardiomyopathy (accumulation, hypertrophy, inflammation, and fibrosis) contributing to the arrhythmia substrate via various intracellular, extracellular, and environmental mechanisms. It is therefore important to understand how these mechanisms contribute to an individual's risk of arrhythmia in FD. In this review, we outline the epidemiology of arrhythmia, pathophysiology of arrhythmogenesis, risk stratification, and cardiac therapy in FD. We explore how advances in conventional cardiac investigations performed in FD patients including 12-lead electrocardiography, transthoracic echocardiography, and cardiac magnetic resonance imaging have enabled early detection of pro-arrhythmic substrate. This has allowed for appropriate risk stratification of FD patients. This paves the way for future work exploring the development of therapeutic initiatives and risk prediction models to reduce the burden of arrhythmia.
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Affiliation(s)
- Ashwin Roy
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.
- Department of Cardiology, University Hospital Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK.
| | - Max J Cumberland
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Christopher O'Shea
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Andrew Holmes
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Manish Kalla
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Cardiology, University Hospital Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Katja Gehmlich
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Division of Cardiovascular Medicine, Department of Medicine and British Heart Foundation Centre of Research Excellence Oxford, University of Oxford, Oxford, UK
| | - Tarekegn Geberhiwot
- Department of Inherited Metabolic Diseases, University Hospital Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
- Institute of Metabolism and System Research, University of Birmingham, Birmingham, UK
| | - Richard P Steeds
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Cardiology, University Hospital Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
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Dilaver RG, Ikizler TA. Personalizing electrolytes in the dialysis prescription: what, why and how? Clin Kidney J 2024; 17:sfad210. [PMID: 38186873 PMCID: PMC10768751 DOI: 10.1093/ckj/sfad210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Indexed: 01/09/2024] Open
Abstract
Maintenance hemodialysis patients suffer from multiple comorbidities and treatment-related complications. A personalized approach to hemodialysis prescription could reduce some of these burdens by preventing complications such as excessive changes in blood pressure, arrhythmias, post-dialysis fatigue and decreased quality of life. A patient-centered approach to dialysate electrolyte concentrations represents one such opportunity. In addition to modifications in dialysate electrolyte concentrations, consideration of individual factors such as patients' serum concentrations, medication profiles, nutritional status and comorbidities is critical to tailoring hemodialysis prescriptions to optimize patient outcomes. The development of personalized dialysis treatment depends on the collection of comprehensive patient data, advances in technology, resource allocation and patient involvement in decision-making. This review discusses how the treatment of maintenance hemodialysis patients could benefit from individualized changes in certain dialysis fluid components.
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Affiliation(s)
- R Gulsah Dilaver
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - T Alp Ikizler
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Yun D, Yang HL, Kwon S, Lee SR, Kim K, Kim K, Lee HC, Jung CW, Kim YS, Han SS. Automatic segmentation of atrial fibrillation and flutter in single-lead electrocardiograms by self-supervised learning and Transformer architecture. J Am Med Inform Assoc 2023; 31:79-88. [PMID: 37949101 PMCID: PMC10746317 DOI: 10.1093/jamia/ocad219] [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: 07/26/2023] [Revised: 10/20/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVES Automatic detection of atrial fibrillation and flutter (AF/AFL) is a significant concern in preventing stroke and mitigating hemodynamic instability. Herein, we developed a Transformer-based deep learning model for AF/AFL segmentation in single-lead electrocardiograms (ECGs) by self-supervised learning with masked signal modeling (MSM). MATERIALS AND METHODS We retrieved data from 11 open-source databases on PhysioNet; 7 of these databases included labeled ECGs, while the other 4 were without labels. Each database contained ECG recordings with durations of ≥30 s. A total of 24 intradialytic ECGs with paroxysmal AF/AFL during 4 h of hemodialysis sessions at Seoul National University Hospital were used for external validation. The model was pretrained by predicting masked areas of ECG signals and fine-tuned by predicting AF/AFL areas. Cross-database validation was used for evaluation, and the intersection over union (IOU) was used as a main performance metric in external database validation. RESULTS In the 7 labeled databases, the areas marked as AF/AFL constituted 41.1% of the total ECG signals, ranging from 0.19% to 51.31%. In the evaluation per ECG segment, the model achieved IOU values of 0.9254 and 0.9477 for AF/AFL segmentation and other segmentation tasks, respectively. When applied to intradialytic ECGs with paroxysmal AF/AFL, the IOUs for the segmentation of AF/AFL and non-AF/AFL were 0.9896 and 0.9650, respectively. Model performance by different training procedure indicated that pretraining with MSM and the application of an appropriate masking ratio both contributed to the model performance. It also showed higher IOUs of AF/AFL labels than in previous studies when training and test databases were matched. CONCLUSION The present model with self-supervised learning by MSM performs robustly in segmenting AF/AFL.
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Affiliation(s)
- Donghwan Yun
- Division of Nephrology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun-Lim Yang
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Soonil Kwon
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - So-Ryoung Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyungju Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kwangsoo Kim
- Transdisciplinary Department of Medicine & Advanced Technology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chul-Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yon Su Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung Seok Han
- Division of Nephrology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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7
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Peng YK, Tai TS, Wu CY, Tsai CY, Lee CC, Chen JJ, Hsiao CC, Chen YC, Yang HY, Yen CL. Clinical outcomes between elderly ESKD patients under peritoneal dialysis and hemodialysis: a national cohort study. Sci Rep 2023; 13:16199. [PMID: 37758848 PMCID: PMC10533893 DOI: 10.1038/s41598-023-43476-1] [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: 08/02/2023] [Accepted: 09/25/2023] [Indexed: 09/29/2023] Open
Abstract
With ageing populations, new elderly end-stage kidney disease (ESKD) cases rise. Unlike younger patients, elderly ESKD patients are less likely to undergo kidney transplant, and therefore the decision of receiving peritoneal dialysis (PD) and hemodialysis (HD) is more crucial. A total of 36,852 patients, aged more than 65, who were newly diagnosed with ESKD and initiated renal replacement therapy between 2013 and 2019 were identified. These patients were categorized into two groups: the PD group and the HD group according to their long-term renal replacement treatment. After propensity score matching, the PD group (n = 1628) displayed a lower incidence of major adverse cardiac and cerebrovascular events (MACCE) (10.09% vs. 13.03%, hazard ratio (HR): 0.74, 95% confidence interval (CI): 0.66-0.83), malignancy (1.23% vs. 2.14%, HR: 0.55, 95% CI: 0.40-0.76), and MACCE-associated mortality (1.35% vs. 2.25%, HR: 0.62, 95% CI: 0.46-0.84) compared to the HD group (n = 6512). However, the PD group demonstrated a higher rate of infection (34.09% vs. 24.14%, HR: 1.28, 95% CI: 1.20-1.37). The risks of all-cause mortality and infection-associated mortality were not different. This study may provide valuable clinical information to assist elderly ESKD patients to choose HD or PD as their renal replacement therapy.
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Affiliation(s)
- Yu-Kai Peng
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tzong-Shyuan Tai
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
| | - Chao-Yi Wu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chung-Ying Tsai
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
| | - Cheng-Chia Lee
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jia-Jin Chen
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ching-Chung Hsiao
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Chang Chen
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Huang-Yu Yang
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Chieh-Li Yen
- Division of Nephrology, Nephrology Department, Kidney Research Center, Linkou Medical Center, Kidney Research Institute, Chang Gung Memorial Hospital, No.5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Gervasoni F, Bellocchio F, Rosenberger J, Arkossy O, Ion Titapiccolo J, Kovarova V, Larkin J, Nikam M, Stuard S, Tripepi GL, Usvyat LA, Winter A, Neri L, Zoccali C. Development and validation of AI-based triage support algorithms for prevention of intradialytic hypotension. J Nephrol 2023; 36:2001-2011. [PMID: 37707692 DOI: 10.1007/s40620-023-01741-6] [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: 02/15/2023] [Accepted: 07/19/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Intradialytic hypotension remains one of the most recurrent complications of dialysis sessions. Inadequate management can lead to adverse outcomes, highlighting the need to develop personalized approaches for the prevention of intradialytic hypotension. Here, we sought to develop and validate two AI-based risk models predicting the occurrence of symptomatic intradialytic hypotension at different time points. METHODS The models were built using the XGBoost algorithm and they predict the occurrence of intradialytic hypotension in the next dialysis session and in the next month. The initial dataset, obtained from routinely collected data in the EuCliD® Database, was split to perform model derivation, training and validation. Model performance was evaluated by concordance statistic and calibration charts; the importance of features was assessed with the Shapley Additive Explanation (SHAP) methodology. RESULTS The final dataset included 1,249,813 dialysis sessions, and the incidence rate of intradialytic hypotension was 10.07% (95% CI 10.02-10.13). Our models retained good discrimination (AUC around 0.8) and a suitable calibration yielding to the selection of three classification thresholds identifying four distinct risk groups. Variables providing the most significant impact on risk estimates were blood pressure dynamics and other metrics mirroring hemodynamic instability over time. CONCLUSIONS Recurrent symptomatic intradialytic hypotension could be reliably and accurately predicted using routinely collected data during dialysis treatment and standard clinical care. Clinical application of these prediction models would allow for personalized risk-based interventions for preventing and managing intradialytic hypotension.
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Affiliation(s)
| | | | - Jaroslav Rosenberger
- FMC-Dialysis Services Slovakia, Kosice, Slovakia
- Medical Faculty, University of PJ Safarik, Kosice, Slovakia
| | - Otto Arkossy
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | | | | | | | - Milind Nikam
- Fresenius Medical Care, Singapore, 307684, Singapore
| | - Stefano Stuard
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | | | | | - Anke Winter
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Luca Neri
- Fresenius Medical Care Italia SpA, Palazzo Pignano, Italy.
| | - Carmine Zoccali
- Renal Research Institute, New York, USA
- Associazione Ipertensione Nefrologia e Trapianto Renale (IPNET) c/o Nefrologia e CNR, Grande Ospedale Metropolitano, Reggio Calabria, Italy
- Biologia E Genetica Molecolare (BIOGEM) Research Center, Ariano Irpino, Avellino, Italy
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9
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Rossum K, Hancock E, Thompson S, Brar R, Riehl-Tonn V, Garcia E, Leon SJ, Sharma M, Ford E, Komenda P, Rigatto C, Tangri N, MacRae JM, Bohm C. A Randomized Trial Examining the Impact of Timing of Intradialytic Cycling on Intradialytic Hypotension. Kidney Int Rep 2023; 8:1002-1012. [PMID: 37180520 PMCID: PMC10166740 DOI: 10.1016/j.ekir.2023.02.1074] [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: 08/15/2022] [Revised: 01/15/2023] [Accepted: 02/08/2023] [Indexed: 02/22/2023] Open
Abstract
Introduction Intradialytic cycling is often performed during the first half of hemodialysis because of concerns regarding increased frequency of intradialytic hypotension (IDH) late in hemodialysis. This increases exercise program resource needs and limits utility of intradialytic cycling to treat dialysis-related symptoms. Methods This multicenter, randomized, crossover trial compared IDH rate when cycling during the first half versus the second half of hemodialysis in 98 adults on maintenance hemodialysis. Group A cycled during the first half of hemodialysis for 2 weeks and subsequently during the second half for 2 weeks. In group B, the cycling schedule was reversed. Blood pressure (BP) was measured every 15 minutes throughout hemodialysis. Primary outcome was IDH rate (systolic BP [SBP] decrease of >20 mm Hg or SBP <90 mm Hg). Secondary outcomes included symptomatic IDH rate and time to recover post hemodialysis. Data were analyzed using negative binomial and gamma distribution mixed regression. Results Mean age 64.7 (SD 12.0) and 64.7 (SD 14.2) years in group A (n = 52) and group B (n = 46), respectively. Proportions of females were 33% in group A and 43% in group B. Median time on hemodialysis was 4.1 (interquartile range [IQR] 2.5, 6.1]) years in group A and 3.9 years (IQR 2.5, 6.7) in group B. IDH rate per 100 hemodialysis hours (95% confidence interval [CI]) was 34.2 (26.4, 42.0) and 36.0 (28.9, 43.1) during early and late intradialytic cycling, respectively (P = 0.53). Timing of intradialytic cycling was not associated with symptomatic IDH (relative risk [RR]: 1.07 [0.75-1.53]) or time to recover post hemodialysis (odds ratio: 0.99 [0.79-1.23]). Conclusion We found no association between the rate of overall or symptomatic IDH and the timing of intradialytic cycling in patients enrolled in an intradialytic cycling program. Increased use of cycling late in hemodialysis may optimize intradialytic cycling program resource use and should be studied as a possible treatment for symptoms common in late hemodialysis.
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Affiliation(s)
- Krista Rossum
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Evelyn Hancock
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Stephanie Thompson
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ranveer Brar
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
| | | | - Eric Garcia
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Manitoba Renal Program, Winnipeg, Manitoba, Canada
| | - Silvia J. Leon
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
| | - Monica Sharma
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Emilie Ford
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
| | - Paul Komenda
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
| | - Claudio Rigatto
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
| | - Navdeep Tangri
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
| | - Jennifer M. MacRae
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Clara Bohm
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
| | - Global Renal Exercise Network6
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Manitoba Renal Program, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
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10
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Kishihara M, Takada T, Jujo K, Shirotani S, Abe T, Yoshida A, Watanabe S, Hagiwara N. Prognostic impact of guideline-directed medical therapy in patients with heart failure on regular hemodialysis. Int J Cardiol 2023; 370:250-254. [PMID: 36270495 DOI: 10.1016/j.ijcard.2022.10.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/15/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Renin-angiotensin system inhibitor (RASi) and β-blocker provide prognostic benefits as guideline-directed medical therapy (GDMT) in patients with heart failure and reduced ejection fraction (HFrEF). However, there is limited data for the favorable effects in such patients receiving regular hemodialysis. We aimed to evaluate the prognostic impact of RASi and β-blocker in patients with HFrEF who receive regular hemodialysis. METHODS In this retrospective, single-center, observational study, from 2110 consecutive patients hospitalized for HF and who survived to discharge, 97 with HFrEF who received regular hemodialysis were included for analysis. They were classified into three groups according to prescribed medication at discharge following index hospitalization: both RASi and β-blocker (Dual-GDMT group: n = 55), either RASi or β-blocker (Mono-GDMT group: n = 34), and neither RASi nor β-blocker (No-GDMT group: n = 8). The primary endpoint was a composite of all-cause death and rehospitalization for heart failure. RESULTS The mean age was 66 years and 79% of the patients were men. During the median follow-up of 501 days, the primary endpoint occurred in 43 patients (44%). Kaplan-Meier analysis revealed that the Dual-GDMT group had the lowest rates of the primary endpoint (log-rank test for trend: p < 0.001). Even after adjustment for diverse covariates (multivariate Cox regression), the Dual-GDMT (hazard ratio [HR]: 0.04, 95% confidence interval (CI): 0.005-0.32) and Mono-GDMT (HR: 0.08, 95% CI: 0.01-0.50) groups had better prognoses than the No-GDMT group. CONCLUSIONS The prescription of RASi and/or β-blocker was associated with a lower adverse-event rate after discharge in patients with HFrEF who were on regular hemodialysis.
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Affiliation(s)
- Makoto Kishihara
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Takuma Takada
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan; Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Japan
| | - Kentaro Jujo
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan.
| | - Shota Shirotani
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Takuro Abe
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Ayano Yoshida
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shonosuke Watanabe
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Nobuhisa Hagiwara
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
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11
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Eden G, Schmidt JJ, Büttner S, Kümpers P, Hafer C, Rovas A, Koch BF, Schmidt BMW, Kielstein JT. Safety and efficacy of the Seraph® 100 Microbind® Affinity Blood Filter to remove bacteria from the blood stream: results of the first in human study. Crit Care 2022; 26:181. [PMID: 35715801 PMCID: PMC9205040 DOI: 10.1186/s13054-022-04044-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 06/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background Bacterial burden as well as duration of bacteremia influence the outcome of patients with bloodstream infections. Promptly decreasing bacterial load in the blood by using extracorporeal devices in addition to anti-infective therapy has recently been explored. Preclinical studies with the Seraph® 100 Microbind® Affinity Blood Filter (Seraph® 100), which consists of heparin that is covalently bound to polymer beads, have demonstrated an effective binding of bacteria and viruses. Pathogens adhere to the heparin coated polymer beads in the adsorber as they would normally do to heparan sulfate on cell surfaces. Using this biomimetic principle, the Seraph® 100 could help to decrease bacterial burden in vivo.
Methods This first in human, prospective, multicenter, non-randomized interventional study included patients with blood culture positive bloodstream infection and the need for kidney replacement therapy as an adjunctive treatment for bloodstream infections. We performed a single four-hour hemoperfusion treatment with the Seraph® 100 in conjunction with a dialysis procedure. Post procedure follow up was 14 days. Results Fifteen hemodialysis patients (3F/12 M, age 74.0 [68.0–78.5] years, dialysis vintage 28.0 [11.0–45.0] months) were enrolled. Seraph® 100 treatment started 66.4 [45.7–80.6] hours after the initial positive blood culture was drawn. During the treatment with the Seraph® 100 with a median blood flow of 285 [225–300] ml/min no device or treatment related adverse events were reported. Blood pressure and heart rate remained stable while peripheral oxygen saturation improved during the treatment from 98.0 [92.5–98.0] to 99.0 [98.0–99.5] %; p = 0.0184. Four patients still had positive blood culture at the start of Seraph® 100 treatment. In one patient blood cultures turned negative during treatment. The time to positivity (TTP) was increased between inflow and outflow blood cultures by 36 [− 7.2 to 96.3] minutes. However, overall TTP increase was not statistical significant. Conclusions Seraph® 100 treatment was well tolerated. Adding Seraph® 100 to antibiotics early in the course of bacteremia might result in a faster resolution of bloodstream infections, which has to be evaluated in further studies. Trail registration: ClinicalTrials.gov Identifier: NCT02914132, first posted September 26, 2016. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04044-7.
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12
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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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13
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Hara T, Kasahara Y, Nakagawa T. Association between haemoglobin concentration and intradialytic hypotension in patients undergoing maintenance haemodialysis: a retrospective cohort study. BMJ Open 2022; 12:e064026. [PMID: 36028275 PMCID: PMC9422893 DOI: 10.1136/bmjopen-2022-064026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Haemoglobin concentration is a potentially modifiable factor that may help lower the risk of intradialytic hypotension (IDH), but its association with IDH is not well understood. This study aimed to clarify the relationship between haemoglobin concentration and IDH. DESIGN Retrospective cohort study. SETTING We evaluated patients undergoing maintenance haemodialysis in December 2017 at Rakuwakai Otowa Kinen Hospital. PARTICIPANTS A total of 543 patients were included. We defined exposure according to the following five categories depending on haemoglobin concentrations by 1.0 increments: <9.0, ≥9.0 to <10.0, 10.0 to <11.0, ≥11.0 to <12.0 and ≥12.0 g/dL. PRIMARY OUTCOME MEASURE The primary outcome of interest was the development of IDH, defined as any nadir <100 mm Hg if the pre-dialysis systolic blood pressure (SBP) was ≥160 mm Hg or any nadir <90 mm Hg if the pre-dialysis SBP was <160 mm Hg (IDHnadir). RESULTS Overall, IDHnadir occurred in 14.3% (465/3250) of the sessions. With a haemoglobin concentration of ≥10.0 to <11.0 g/dL set as reference, the adjusted ORs for IDHnadir were 0.82 (95% CI, 0.32 to 2.15), 1.16 (95% CI, 0.56 to 2.39), 1.26 (95% CI, 0.68 to 2.36) and 3.01 (95% CI, 1.50 to 6.07) for haemoglobin concentrations of <9.0, ≥9.0 to <10.0, ≥11.0 to <12.0 and ≥12.0 g/dL, respectively. In the cubic spline analysis, a high haemoglobin concentration was associated with the development of IDHnadir. CONCLUSION High haemoglobin concentration is associated with IDH, and thus, the upper limit of haemoglobin concentration should be closely monitored in patients with IDH.
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Affiliation(s)
- Takashi Hara
- Department of Nephrology, Rakuwakai Otowa Hospital, Kyoto, Japan
| | - Yuto Kasahara
- Department of Nephrology, Rakuwakai Otowa Hospital, Kyoto, Japan
| | - Takahiko Nakagawa
- Department of Nephrology, Rakuwakai Otowa Hospital, Kyoto, Japan
- Department of Biochemistry, Shiga University of Medical Science, Otsu, Japan
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14
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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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Causland FRM, Ravi KS, Curtis KA, Kibbelaar ZA, Short SAP, Singh AT, Correa S, Waikar SS. A randomized controlled trial of two dialysate sodium concentrations in hospitalized hemodialysis patients. Nephrol Dial Transplant 2022; 37:1340-1347. [PMID: 34792161 PMCID: PMC9217525 DOI: 10.1093/ndt/gfab329] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Several large dialysis organizations have lowered the dialysate sodium concentration (DNa) in an effort to ameliorate hypervolemia. The implications of lower DNa on intra-dialytic hypotension (IDH) during hospitalizations of hemodialysis (HD) patients is unclear. METHODS In this double-blind, single center, randomized controlled trial (RCT), hospitalized maintenance HD patients were randomized to receive higher (142 mmol/L) or lower (138 mmol/L) DNa for up to six sessions. Blood pressure (BP) was measured in a standardized fashion pre-HD, post-HD and every 15 min during HD. The endpoints were: (i) the average decline in systolic BP (pre-HD minus lowest intra-HD, primary endpoint) and (ii) the proportion of total sessions complicated by IDH (drop of ≥20 mmHg from the pre-HD systolic BP, secondary endpoint). RESULTS A total of 139 patients completed the trial, contributing 311 study visits. There were no significant differences in the average systolic blood pressure (SBP) decline between the higher and lower DNa groups (23 ± 16 versus 26 ± 16 mmHg; P = 0.57). The proportion of total sessions complicated by IDH was similar in the higher DNa group, compared with the lower DNa group [54% versus 59%; odds ratio 0.72; 95% confidence interval (95% CI) 0.36-1.44; P = 0.35]. In post hoc analyses adjusting for imbalances in baseline characteristics, higher DNa was associated with 8 mmHg (95% CI 2-13 mmHg) less decline in SBP, compared with lower DNa. Patient symptoms and adverse events were similar between the groups. CONCLUSIONS In this RCT for hospitalized maintenance of HD patients, we found no difference in the absolute SBP decline between those who received higher versus lower DNa in intention-to-treat analyses. Post hoc adjusted analyses suggested a lower risk of IDH with higher DNa; thus, larger, multi-center studies to confirm these findings are warranted.
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Affiliation(s)
- Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Katherine Scovner Ravi
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Katherine A Curtis
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Zoé A Kibbelaar
- Renal Section, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Samuel A P Short
- Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Anika T Singh
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Simon Correa
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sushrut S Waikar
- Renal Section, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
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16
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Uchida T, Ookawara S, Ito K, Okada H, Hayasaka H, Kofuji M, Kimura M, Ueda Y, Hasebe T, Momose N, Morishita Y. Lethal ventricular arrhythmia can be prevented by adjusting the dialysate potassium concentration and the use of anti-arrhythmic agents: a case report and literature review. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-022-00410-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hypokalemia is common in patients with malnutrition undergoing hemodialysis and is often involved in the development of lethal arrhythmia. Moreover, hemodialysis therapy decreases the serum potassium concentration due to potassium removal to the dialysate. However, it is difficult to adjust the dialysate potassium concentration owing to the use of the central dialysate delivery system in Japan. Here, we have presented a case undergoing hemodialysis with dialysate potassium concentration adjustment to prevent ventricular arrhythmia.
Case presentation
A 56-year-old man with Emery-Dreifuss muscular dystrophy and chronic heart failure was admitted to our hospital and needed subsequent hemodialysis therapy due to renal dysfunction. During hemodialysis, the cardiac resynchronization therapy defibrillator was activated to the treatment of his lethal ventricular arrhythmia. Decreases in serum potassium concentration after hemodialysis and changes in serum potassium concentration during HD were considered the causes of lethal ventricular arrythmia. Therefore, along with using anti-arrhythmic agents, the dialysate potassium concentration was increased from 2.0 to 3.5 mEq/L to minimize changes in the serum potassium concentration during hemodialysis. Post-dialysis hypokalemia disappeared and these changes during hemodialysis were minimized, and no lethal ventricular arrhythmia occurred thereafter.
Conclusions
In this case, we prevented lethal arrhythmia by maintaining the serum potassium concentration by increasing the dialysate potassium concentration, in addition to the use of anti-arrhythmic agents. In the acute phase of patients with frequent lethal arrhythmia undergoing hemodialysis, an increase in dialysate potassium concentration may be an effective method for preventing arrhythmogenic complications.
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17
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Hara T, Kasahara Y, Nakagawa T. Pre-dialysis diastolic blood pressure and intradialytic hypotension in patients undergoing maintenance haemodialysis. J Nephrol 2022; 35:1419-1426. [PMID: 35247180 DOI: 10.1007/s40620-022-01292-2] [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: 12/18/2021] [Accepted: 02/17/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intradialytic hypotension is a clinically relevant complication in haemodialysis patients. Pre-dialysis diastolic blood pressure is routinely measured. However, the association between pre-dialysis diastolic blood pressure and intradialytic hypotension is not well understood. METHODS Patient-level (N = 545) and haemodialysis session-level (N = 3261) data were collected; the exposure variable was pre-dialysis diastolic blood pressure. The primary outcome of interest was the development of intradialytic hypotension, defined as any nadir < 100 mmHg if the pre-dialysis systolic blood pressure was ≥ 160 mmHg, or any nadir < 90 mmHg if the pre-dialysis systolic blood pressure was < 160 mmHg. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using mixed-effects logistic regression for the association between pre-dialysis diastolic blood pressure and intradialytic hypotension, after adjusting for potential confounders. RESULTS Intradialytic hypotension occurred in 14.4% of the sessions. All sessions were divided into five categories according to pre-dialysis diastolic blood pressure. The adjusted ORs for intradialytic hypotension were 2.72 (95% CI 1.64-4.51), 1.07 (95% CI 0.68-1.66), 1.68 (95% CI 1.08-2.62), and 1.81 (95% CI 1.05-3.14) in sessions with pre-dialysis diastolic blood pressure of < 60 mmHg, ≥ 60 to < 70 mmHg, ≥ 80 to < 90 mmHg, and ≥ 90 mmHg, respectively, compared with the reference pre-dialysis diastolic blood pressure of ≥ 70 to < 80 mmHg. Cubic spline analyses revealed a reverse J-shaped association between pre-dialysis diastolic blood pressure and intradialytic hypotension. CONCLUSIONS Low and high pre-dialysis diastolic blood pressure levels were associated with intradialytic hypotension. This may help identify patients at a high risk of developing intradialytic hypotension.
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Affiliation(s)
- Takashi Hara
- Department of Nephrology, Rakuwakai Otowa Hospital, 2 Otowa-Chinji-cho, Yamashina-ku, Kyoto, 607-8062, Japan.
| | - Yuto Kasahara
- Department of Nephrology, Rakuwakai Otowa Hospital, 2 Otowa-Chinji-cho, Yamashina-ku, Kyoto, 607-8062, Japan
| | - Takahiko Nakagawa
- Department of Nephrology, Rakuwakai Otowa Hospital, 2 Otowa-Chinji-cho, Yamashina-ku, Kyoto, 607-8062, Japan.,Department of Biochemistry, Shiga University of Medical Science, Shiga, Japan
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18
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Pstras L, Stachowska-Pietka J, Debowska M, Pietribiasi M, Poleszczuk J, Waniewski J. Dialysis therapies: Investigation of transport and regulatory processes using mathematical modelling. Biocybern Biomed Eng 2022. [DOI: 10.1016/j.bbe.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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19
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Albakr RB, Bargman JM. A Comparison of Hemodialysis and Peritoneal Dialysis in Patients with Cardiovascular Disease. Cardiol Clin 2021; 39:447-453. [PMID: 34247757 DOI: 10.1016/j.ccl.2021.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The high prevalence of cardiovascular disease is caused by the traditional cardiovascular risk factors common among end-stage renal disease patients, and nontraditional risk factors attributed to underlying kidney disease, including chronic inflammation, anemia, bone mineral disease, and the dialysis procedure itself. Individualization of the treatment of cardiovascular disease in end-stage renal disease that could impact the underlying mechanisms of the cardiovascular diseases is important to improve outcomes. This article reviews and compares hemodialysis and peritoneal dialysis in association with different cardiovascular diseases affecting dialysis patients, including hypertension, coronary artery disease, myocardial stunning, cardiac arrhythmias, heart failure, and the cardiorenal syndrome.
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Affiliation(s)
- Rehab B Albakr
- Division of Nephrology, University of Toronto, University Health Network, 200 Elizabeth Street 8N-840, Toronto, ON M5G 2C4, Canada; Division of Nephrology, College of Medicine, King Saud University, King Khalid Street, Riyadh-Al-Diriyah 12372, Saudi Arabia
| | - Joanne M Bargman
- Division of Nephrology, University of Toronto, University Health Network/Toronto General Hospital, 200 Elizabeth Street, 8N-840, Toronto, Ontario M5G 2C4, Canada.
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20
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Ravi KS, Reeves PB, Correa S, Neves JS, Waikar SS, Mothi SS, Mc Causland FR. Predialysis serum phosphate and intradialytic hypotension. Hemodial Int 2021; 26:38-47. [PMID: 34236130 DOI: 10.1111/hdi.12971] [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: 03/22/2021] [Revised: 06/25/2021] [Accepted: 06/26/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Intradialytic hypotension (IDH) is a common complication of hemodialysis (HD) and is associated with excess morbidity and mortality. Higher serum phosphate is associated with adverse cardiovascular outcomes in maintenance HD patients; however, its association with IDH has not previously been assessed. METHODS This is an analysis of a prospective cohort of 969 HD patients (80,968 HD sessions) receiving HD at a large dialysis organization (LDO) and a post-hoc analysis of 1838 HD patients (10,594 HD sessions) in the Hemodialysis study (HEMO), a multicenter randomized controlled trial that examined standard or high-dose HD and low-flux or high-flux membranes. Unadjusted and adjusted mixed effects regression models were fit to determine the association of pre-HD serum phosphate with IDH, defined as a nadir intra-HD systolic blood pressure (SBP) <90 mmHg. FINDINGS In the LDO cohort, baseline mean pre-HD serum phosphate was 5.2 ± 1.7 mg/dl. IDH occurred in 15.6% of HD sessions. In the adjusted model, higher pre-HD serum phosphate (per 1 mg/dl) was associated with a 12% increased risk of IDH (aOR 1.12, 95% CI 1.10-1.13, p <0.001). In exploratory models where pre-HD laboratory values were available, the effect estimate was attenuated but remained statistically significant (aOR 1.05; 95% CI 1.02-1.08; p <0.01). Participants in the highest (compared with the lowest) quartile of pre-HD serum phosphate had a 56% greater risk of IDH in the adjusted model (aOR Q4:Q1 1.56; 95% CI 1.44-1.68, p <0.001). The association of higher phosphate with IDH was consistent in the HEMO data. DISCUSSION Higher pre-HD serum phosphate is independently associated with an increased risk of IDH. As HD may cause an acute decline in serum phosphate, future studies to investigate the mechanisms of this association are warranted.
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Affiliation(s)
- Katherine Scovner Ravi
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Patrick B Reeves
- Kidney Specialists of Central Oklahoma, Oklahoma City, Oklahoma, USA
| | - Simon Correa
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - João Sérgio Neves
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Sushrut S Waikar
- Renal Section, Department of Medicine, Boston University Medical Center, Boston, Massachusetts, USA
| | - Suraj S Mothi
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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21
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Miller BW. Reconciling the Current Status of Home Hemodialysis With the 2019 Executive Order-Realistic or Obtainable? Adv Chronic Kidney Dis 2021; 28:124-128. [PMID: 34717857 DOI: 10.1053/j.ackd.2020.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 11/09/2020] [Accepted: 11/19/2020] [Indexed: 11/11/2022]
Abstract
The Advancing American Kidney Health Initiative places financial incentives largely aimed at nephrologists and dialysis providers, but including other health care providers, in an attempt to improve clinical outcomes and lower costs in the chronic kidney disease population. Both peritoneal and home hemodialysis utilization will need to be markedly increased to achieve these policy goals. This article looks at some of the concerns that may stand in the way of achieving those goals.
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22
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Lai AC, Bienstock SW, Sharma R, Skorecki K, Beerkens F, Samtani R, Coyle A, Kim T, Baber U, Camaj A, Power D, Fuster V, Goldman ME. A Personalized Approach to Chronic Kidney Disease and Cardiovascular Disease: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 77:1470-1479. [PMID: 33736830 DOI: 10.1016/j.jacc.2021.01.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 01/11/2023]
Abstract
Cardiovascular disease is the most common cause of death in patients with end-stage renal disease (ESRD). The initiation of dialysis for treatment of ESRD exacerbates chronic electrolyte and hemodynamic perturbations. Rapid large shifts in effective intravascular volume and electrolyte concentrations ultimately lead to subendocardial ischemia, increased left ventricular wall mass, and diastolic dysfunction, and can precipitate serious arrhythmias through a complex pathophysiological process. These factors, unique to advanced kidney disease and its treatment, increase the overall incidence of acute coronary syndrome and sudden cardiac death. To date, risk prediction models largely fail to incorporate the observed cardiovascular mortality in the CKD population; however, multimodality imaging may provide an additional prognostication and risk stratification. This comprehensive review discusses the cardiovascular risks associated with hemodialysis, and explores the pathophysiology and the novel utilization of multimodality imaging in CKD to promote a personalized approach for these patients with implications for future research.
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Affiliation(s)
- Ashton C Lai
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | | | - Raman Sharma
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Karl Skorecki
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Frans Beerkens
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Rajeev Samtani
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Andrew Coyle
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Tonia Kim
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Usman Baber
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Anton Camaj
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - David Power
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Valentin Fuster
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Martin E Goldman
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA.
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23
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Monardo P, Lacquaniti A, Campo S, Bucca M, Casuscelli di Tocco T, Rovito S, Ragusa A, Santoro A. Updates on hemodialysis techniques with a common denominator: The personalization of the dialytic therapy. Semin Dial 2021; 34:183-195. [PMID: 33592133 DOI: 10.1111/sdi.12956] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/02/2020] [Indexed: 12/14/2022]
Abstract
Hemodialysis (HD) is a life-saving therapy for patients with end-stage renal disease. In dialyzed patients, the prevalence of multi-morbidity is rising driven by various factors, such as the population aging, the incomplete correction of uremia, and the side effects of the dialysis therapy itself. Each dialyzed patient has their own specific clinical and biochemical problems. It is therefore unthinkable that the same dialysis procedure can be able to meet the needs of every patient on chronic dialysis. We have very sophisticated dialysis machines and different dialysis techniques and procedures beyond conventional HD, such as hemodiafiltration (HDF) with pre- and post-dilution, acetate-free biofiltration (AFB), hemofiltration (HF), and expanded HD. Each of these techniques has its own specific characteristics. To solve some intradialytic clinical issues, such as arterial hypotension and arrhythmias, we have biofeedback systems with automatic regulation of the blood volume, body temperature, arterial pressure, as well as potassium profiling techniques in the dialysis bath. New technical innovations, such as citrate-containing dialysate or heparin-coated membranes, could reduce the risk of bleeding. To better address to patient needs, the strengths and weaknesses of each of these systems must be well-known, in order to have a personalized dialysis prescription for each patient.
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Affiliation(s)
- Paolo Monardo
- Nephrology and Dialysis Unit, Papardo Hospital, Messina, Italy
| | | | - Susanna Campo
- Nephrology and Dialysis Unit, Papardo Hospital, Messina, Italy
| | - Maurizio Bucca
- Nephrology and Dialysis Unit, Papardo Hospital, Messina, Italy
| | | | - Stefania Rovito
- Nephrology and Dialysis Unit, Papardo Hospital, Messina, Italy
| | - Antonino Ragusa
- Nephrology and Dialysis Unit, Papardo Hospital, Messina, Italy
| | - Antonio Santoro
- Department of Organ Failures and Transplantations, Policlinico S.Orsola-Malpighi- Bologna, Italy
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24
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Álvarez Nadal M, Martín Capón I, Viera Ramírez ER, Fernández Lucas M. Absolute blood volume variations during hemodialysis: Does dialysate temperature play a role? Semin Dial 2021; 34:309-314. [PMID: 33580986 DOI: 10.1111/sdi.12958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/14/2020] [Accepted: 01/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Vascular refilling occurs to preserve hemodynamic stability during hemodialysis (HD). Recent studies report a feasible and noninvasive method to determine absolute blood volume (ABV), and estimate vascular refilling during HD. The objective of this study is to analyze if lowering dialysate temperature modifies variations in ABV during HD. METHODS The study was performed in 50 patients under HD. During two different sessions, relative blood volume was assessed using dialysate temperatures of 35.5°C (cool dialysate) and 36.5°C (neutral dialysate). ABV and vascular refilling were calculated using Kron et al methodology. RESULTS Thirty-nine intradialytic morbid events (IMEs) were observed in 30 patients, 14 under cool dialysate and 25 during neutral dialysate. We did not found statistically differences in ABV or in refilling volume between cool and neutral temperature. When analyzing apart only those patients who presented IME, we observed lower drop in ABV in the 35.5°C dialysate treatments (0.57 L) versus 36.5°C dialysate treatments (0.71 L). When cool dialysate was used, the vascular refilling fraction tended to be higher, but data did not turn statistically significant. CONCLUSIONS In selected groups of patients the use of cool dialysate induces lower ABV variations that could improve hemodynamic stability during HD treatments.
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Affiliation(s)
- Marta Álvarez Nadal
- Department of Nephrology, IRYCIS, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Irene Martín Capón
- Department of Nephrology, IRYCIS, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Milagros Fernández Lucas
- Department of Nephrology, IRYCIS, Hospital Universitario Ramón y Cajal, Madrid, Spain.,Universidad de Alcalá, Madrid, Spain
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