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Bae TW, Park JH, Park JW, Kwon KK, Kim KY. Visual Indicator for Intradialytic Hypotension Prediction Using Variation and Compensation of Heart Rate. Diagnostics (Basel) 2024; 14:2664. [PMID: 39682571 DOI: 10.3390/diagnostics14232664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2024] [Revised: 11/24/2024] [Accepted: 11/25/2024] [Indexed: 12/18/2024] Open
Abstract
BACKGROUND To date, most intradialytic hypotension (IDH) studies have proposed technologies to comprehensively predict the occurrence of IDH using the patient's baseline information and ultrafiltration (UF) information, but it is difficult to apply the technologies while identifying the patient's condition in real time. METHODS In this study, we propose an IDH indicator that uses heart rate (HR) change information to identify the patient's condition in real time and visually shows whether IDH has occurred. The data used were collected from 40 dialysis patients in a clinical trial conducted in the Artificial Kidney Unit at Yeungnam University Medical Center, Korea, from 18 July to 29 November 2023. RESULTS The IDH indicator infers changes in the patient's blood pressure during dialysis by analyzing the upper and lower maximum HRs based on the real-time average HR. Medical staff can respond to IDH in real time by looking at the IDH indicator, which visually expresses changes in the patient's HR. In addition, we propose a multilayer perceptron structure that inputs upper and lower maximum HR information based on the average HR for the time interval accumulated in real time. In learning using 40 min of data up to 5 min before IDH occurred, models using two and five layers showed excellent performance, with accuracy of 88.6% and 85.2%, respectively. CONCLUSIONS By combining IDH visual indicators and the multi-layer perceptron method, medical staff can effectively respond to IDH in real time.
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Affiliation(s)
- Tae-Wuk Bae
- Daegu-Gyeongbuk Research Center, Electronics and Telecommunications Research Institute, Daegu 42994, Republic of Korea
| | - Ji-Hyun Park
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
| | - Jong-Won Park
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
| | - Kee-Koo Kwon
- Daegu-Gyeongbuk Research Center, Electronics and Telecommunications Research Institute, Daegu 42994, Republic of Korea
| | - Kwang-Yong Kim
- Daegu-Gyeongbuk Research Center, Electronics and Telecommunications Research Institute, Daegu 42994, Republic of Korea
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Marshall MR, Wang MY, Vandal AC, Dunlop JL. Low dialysate sodium levels for chronic haemodialysis. Cochrane Database Syst Rev 2024; 11:CD011204. [PMID: 39498822 PMCID: PMC11536490 DOI: 10.1002/14651858.cd011204.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2024]
Abstract
BACKGROUND Cardiovascular (CV) disease is the leading cause of death in dialysis patients and is strongly associated with fluid overload and hypertension. It is plausible that low dialysate sodium ion concentration [Na+] may decrease total body sodium content, thereby reducing fluid overload and hypertension and ultimately reducing CV morbidity and death. This is an update of a review first published in 2019. OBJECTIVES This review evaluated the harms and benefits of using a low (< 138 mM) dialysate [Na+] for maintenance haemodialysis (HD) patients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 1 October 2024 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs), both parallel and cross-over, of low (< 138 mM) versus neutral (138 to 140 mM) or high (> 140 mM) dialysate [Na+] for maintenance HD patients were included. DATA COLLECTION AND ANALYSIS Two authors independently screened studies for inclusion and extracted data. Statistical analyses were performed using the random-effects model, and results expressed as risk ratios (RR) for dichotomous outcomes, and mean differences (MD) or standardised MD (SMD) for continuous outcomes, with 95% confidence intervals (CI). Confidence in the evidence was assessed using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). MAIN RESULTS We included 17 studies randomising 509 patients, with data available for 452 patients after dropouts. All but three studies evaluated a fixed concentration of low dialysate [Na+], with one using profiled dialysate [Na+] and two using individualised dialysate [Na+]. Five were parallel group studies, and 12 were cross-over studies. Of the latter, only six used a washout between intervention and control periods. Most studies were short-term with a median (interquartile range) follow-up of 4 (4 to 16) weeks. Two were of a single HD session and two of a single week's HD. Seven studies were conducted prior to 2000, and six reported the use of obsolete HD practices. Other than for indirectness arising from older studies, risks of bias in the included studies were generally low. Compared to neutral or high dialysate [Na+] (≥ 138 mM), low dialysate [Na+] (< 138 mM) reduces interdialytic weight gain (14 studies, 515 participants: MD -0.36 kg, 95% CI -0.50 to -0.22; high certainty evidence) and antihypertensive medication use (5 studies, 241 participants: SMD -0.37, 95% CI -0.64 to -0.1; high certainty evidence), and probably reduces left ventricular mass index (2 studies, 143 participants: MD -7.65 g/m2, 95% CI -14.48 to -0.83; moderate certainty evidence), predialysis mean arterial pressure (MAP) (5 studies, 232 participants: MD -3.39 mm Hg, 95% CI -5.17 to -1.61; moderate certainty evidence), postdialysis MAP (5 studies, 226 participants: MD -3.17 mm Hg, 95% CI -4.68 to 1.67; moderate certainty evidence), predialysis serum [Na+] (11 studies, 435 participants: MD -1.26 mM, 95% CI -1.81 to -0.72; moderate certainty evidence) and postdialysis serum [Na+] (6 studies, 188 participants: MD -3.09 mM, 95% CI -4.29 to -1.88; moderate certainty evidence). Compared to neutral or high dialysate [Na+], low dialysate [Na+] probably increases intradialytic hypotension events (13 studies, 15,764 HD sessions: RR 1.58, 95% 1.25 to 2.01; moderate certainty evidence) and intradialytic cramps (10 studies, 14,559 HD sessions: RR 1.84, 95% 1.29 to 2.64; moderate certainty evidence). Effect size for important outcomes were generally greater with low dialysate [Na+] compared to high compared with neutral dialysate [Na+], although formal hypothesis testing identifies that the difference was only certain for postdialysis serum [Na+]. Compared to neutral or high dialysate [Na+], it is uncertain whether low dialysate [Na+] affects intradialytic or interdialytic MAP, and dietary salt intake. It is also uncertain whether low dialysate [Na+] changed extracellular fluid status, venous tone, arterial vascular resistance, left ventricular volumes, or fatigue. Studies did not examine CV or all-cause death, CV events, or hospitalisation. AUTHORS' CONCLUSIONS Low dialysate [Na+] reduces intradialytic weight gain and probably blood pressure, which are effects directionally associated with improved outcomes. However, the intervention probably increases intradialytic hypotension and probably reduces serum [Na+], effects that are associated with an increased risk of death. The effect of the intervention on overall patient health and well-being is unknown. Further evidence is needed in the form of longer-term studies in contemporary settings, evaluating end-organ effects in small-scale mechanistic studies using optimal methods, and clinical outcomes in large-scale multicentre RCTs.
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Affiliation(s)
- Mark R Marshall
- Department of Medicine, Te Whatu Ora Hauora a Toi Bay of Plenty, Tauranga, New Zealand
- School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Millie Yue Wang
- Department of Medicine, New Zealand Clinical Research, Auckland, New Zealand
| | - Alain C Vandal
- Department of Statistics, University of Auckland, Auckland, New Zealand
| | - Joanna L Dunlop
- Department of Medicine, Counties Manukau Health, Auckland, New Zealand
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Blunier AL, Cheatham MR, Deodhar KS, Geik CA, Walroth TA, Whitten JA, Davis CM. Evaluation of a Pharmacist-Led Implementation of Standardized Medication Administration Times for Inpatients Receiving Hemodialysis. Ann Pharmacother 2024; 58:1027-1033. [PMID: 38293819 DOI: 10.1177/10600280231220079] [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] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Missed medication doses are a common and often preventable medication-related error that have been associated with an increased length of stay and mortality. Hemodialysis is a common, relatively predictable reason that patients are unavailable, resulting in missed doses. OBJECTIVE To evaluate the implications of a pharmacist-led intervention to standardize the medication administration times for patients requiring hemodialysis who were prescribed antihypertensives, antiepileptics, apixaban, and/or antimicrobials. METHODS A retrospective preanalysis and postanalysis of a pharmacist-led intervention were performed at a single-center, safety net hospital. Patients receiving dialysis and prescribed one of the targeted medications were included. The primary endpoint was the composite of missed and delayed doses. RESULTS A total of 25 patients receiving 126 dialysis sessions in the preintervention group and 29 patients receiving 80 dialysis sessions in the postintervention group were included for analysis. For the primary endpoint, 118 (18%) versus 57 (9.3%) doses were missed or delayed in the preintervention versus postintervention group, respectively (P < 0.001). The primary endpoint was driven by fewer delayed doses in the postgroup. The number of antimicrobials given on a correct schedule increased in the postintervention group (98.3% vs 99.1%, P = 0.044). CONCLUSION AND RELEVANCE A pharmacist-led intervention for standard medication administration times in patients requiring hemodialysis increased the number of prescribed medication doses given and given on time. The intervention also led to more antimicrobials administered at appropriate times relative to dialysis sessions.
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Affiliation(s)
- Abbie L Blunier
- Department of Pharmacy, Eskenazi Health, Indianapolis, IN, USA
- Prisma Health Richland Hospital, Columbia, SC, USA
| | | | | | | | - Todd A Walroth
- Department of Pharmacy, Eskenazi Health, Indianapolis, IN, USA
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Arcentales-Vera K, Vera-Mendoza MF, Cevallos-Salas C, García-Aguilera MF, Fuenmayor-González L. Prevalence of cardiovascular instability during hemodialysis therapy in hospitalized patients: A systematic review and meta-analysis. Sci Prog 2024; 107:368504241308982. [PMID: 39726219 DOI: 10.1177/00368504241308982] [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] [Indexed: 12/28/2024]
Abstract
BACKGROUND Intradialytic hypotension (IDH) is a common and serious complication in renal replacement therapy, especially in hospitalized patients. The absence of a standardized definition complicates data synthesis and the development of evidence-based guidelines. Current definitions vary, including different blood pressure thresholds, clinical symptoms, and the need for medical intervention during dialysis. IDH is linked to increased mortality and cardiovascular morbidity and may impede renal recovery in patients with acute kidney injury and chronic kidney disease. METHODS A systematic review was conducted using MEDLINE via PubMed, Embase, and Web of Science to identify studies reporting IDH prevalence. A meta-analysis of proportions was performed to determine the global prevalence of IDH, with subgroup analyses to explore heterogeneity. The Joanna Briggs Institute's checklist was used to assess the risk of bias in prevalence studies. The PRISMA guidelines were followed to report the results of this study, PROSPERO registration number CRD42024500622. RESULTS The meta-analysis found a global IDH prevalence of 31% (95% CI 0.18-0.44) across nine studies. Significant heterogeneity was observed (I²: 97.87%; p < 0.01), with prevalence rates ranging from 10.7% to 64% based on patient demographics and session characteristics. Sensitivity analysis suggested prevalence could range between 27% and 33% depending on study criteria. CONCLUSIONS IDH is a significant complication during hospital-based renal replacement therapy, with a global prevalence of 31%. These findings highlight the need for a standardized, evidence-based definition of IDH to improve diagnostic consistency and clinical outcomes through more accurate diagnosis, better treatment strategies, and tailored patient management.
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Affiliation(s)
- Karla Arcentales-Vera
- Postgrado en Medicina Crítica y Terapia Intensiva, Facultad de Ciencias Médicas, Universidad Central del Ecuador, Quito, Ecuador
| | - María Fernanda Vera-Mendoza
- Postgrado en Medicina Crítica y Terapia Intensiva, Facultad de Ciencias Médicas, Universidad Central del Ecuador, Quito, Ecuador
| | - Cristian Cevallos-Salas
- Postgrado en Medicina Crítica y Terapia Intensiva, Facultad de Ciencias Médicas, Universidad Central del Ecuador, Quito, Ecuador
- Unidad de Terapia Intensiva, Hospital de Especialidades Carlos Andrade Marín, Quito, Ecuador
| | - María Fernanda García-Aguilera
- Postgrado en Medicina Crítica y Terapia Intensiva, Facultad de Ciencias Médicas, Universidad Central del Ecuador, Quito, Ecuador
- Doctorado en Ciencias Médicas, Universidad de la Frontera, Temuco, Chile
- Unidad de Revisiones Sistemáticas y Metaanálisis-URMA, Facultad de Ciencias Médicas, Universidad Central del Ecuador, Quito, Ecuador
| | - Luis Fuenmayor-González
- Postgrado en Medicina Crítica y Terapia Intensiva, Facultad de Ciencias Médicas, Universidad Central del Ecuador, Quito, Ecuador
- Unidad de Revisiones Sistemáticas y Metaanálisis-URMA, Facultad de Ciencias Médicas, Universidad Central del Ecuador, Quito, Ecuador
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Yang IN, Liu CF, Chien CC, Wang HY, Wang JJ, Shen YT, Chen CC. Personalized prediction of intradialytic hypotension in clinical practice: Development and evaluation of a novel AI dashboard incorporating risk factors from previous and current dialysis sessions. Int J Med Inform 2024; 190:105538. [PMID: 38968689 DOI: 10.1016/j.ijmedinf.2024.105538] [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: 04/11/2023] [Revised: 10/18/2023] [Accepted: 07/01/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND Intradialytic hypotension (IDH) is one of the most common and critical complications of hemodialysis. Despite many proven factors associated with IDH, accurately predicting it before it occurs for individual patients during dialysis sessions remains a challenge. PURPOSE To establish artificial intelligence (AI) predictive models for IDH, which consider risk factors from previous and ongoing dialysis to optimize model performance. We then implement a novel digital dashboard with the best model for continuous monitoring of patients' status undergoing hemodialysis. The AI dashboard can display the real-time probability of IDH for each patient in the hemodialysis center providing an objective reference for care members for monitoring IDH and treating it in advance. METHODS Eight machine learning (ML) algorithms, including Logistic Regression (LR), Random Forest (RF), Support Vector Machine (SVM), K Nearest Neighbor (KNN), Light Gradient Boosting Machine (LightGBM), Multilayer Perception (MLP), eXtreme Gradient Boosting (XGBoost), and NaiveBayes, were used to establish the predictive model of IDH to determine if the patient will acquire IDH within 60 min. In addition to real-time features, we incorporated several features sourced from previous dialysis sessions to improve the model's performance. The electronic medical records of patients who had undergone hemodialysis at Chi Mei Medical Center between September 1, 2020 and December 31, 2020 were included in this research. Impact evaluation of AI assistance was conducted by IDH rate. RESULTS The results showed that the XGBoost model had the best performance (accuracy: 0.858, sensitivity: 0.858, specificity: 0.858, area under the curve: 0.936) and was chosen for AI dashboard implementation. The care members were delighted with the dashboard providing real-time scientific probabilities for IDH risk and historic predictive records in a graphic style. Other valuable functions were appended in the dashboard as well. Impact evaluation indicated a significant decrease in IDH rate after the application of AI assistance. CONCLUSION This AI dashboard provides high-quality results in IDH risk prediction during hemodialysis. High-risk patients for IDH will be recognized 60 min earlier, promoting individualized preventive interventions as part of the treatment plan. Our approachis believed to promise an excellent way for IDH management.
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Affiliation(s)
- I-Ning Yang
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan; Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Feng Liu
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan.
| | - Chih-Chiang Chien
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Hsien-Yi Wang
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan; Department of Sport Management, College of Leisure and Recreation Management, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Jhi-Joung Wang
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Ting Shen
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Chia-Chun Chen
- Department of Information Systems, Chi Mei Medical Center, Liouying Tainan, Taiwan.
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Kawasaki S, Sakai Y, Harasawa S, Inatsu A, Kubota Y, Hirama A, Kashiwagi T, Iwabu M. The efficacy and safety of ivabradine hydrochloride in hemodialysis patients with chronic heart failure. Ther Apher Dial 2024; 28:354-363. [PMID: 38199237 DOI: 10.1111/1744-9987.14107] [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: 10/25/2023] [Revised: 12/20/2023] [Accepted: 12/27/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION There is little evidence for ivabradine hydrochloride in patients undergoing hemodialysis. METHODS In this open-label prospective interventional trial of hemodialysis patients with chronic heart failure, during 12 weeks of treatment, changes in Heart rate (HR), frequency of dialysis-related hypotension were examined, and we investigated health-related quality of life (HR-QOL) and adverse effects. RESULTS 18 patients from 6 facilities were enrolled in the study. HR significantly decreased over time, from 87 ± 12.61/min at baseline to 75.85 ± 8.91/min (p = 0.0003), and systolic blood pressure also increased significantly (p < 0.0001). The frequency of dialysis-related hypotension was markedly reduced (p = 0.0001). The HR-QOL survey showed significant improvements in Social Functioning among others (p = 0.0178). No specific adverse events occurred. CONCLUSION Ivabradine hydrochloride improved dialysis-related hypotension. Furthermore, the HR-QOL improvement effect were suggested. These results demonstrated the safety and effectiveness of ivabradine hydrochloride.
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Affiliation(s)
- Sayuri Kawasaki
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
- Akihabara Kidney Clinic, Tokyo, Japan
- Ayase-ekimae Kidney Clinic, Tokyo, Japan
| | - Yukinao Sakai
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | | | | | - Yoshiaki Kubota
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Akio Hirama
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
- Kidney Clinic of Nippon Medical School, Tokyo, Japan
| | - Tetsuya Kashiwagi
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Masato Iwabu
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
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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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Kolben Y, Gork I, Peled D, Amitay S, Moshel P, Goldstein N, Ben Ishay A, Fons M, Tabi M, Eisenkraft A, Gepner Y, Nachman D. Continuous Monitoring of Advanced Hemodynamic Parameters during Hemodialysis Demonstrated Early Variations in Patients Experiencing Intradialytic Hypotension. Biomedicines 2024; 12:1177. [PMID: 38927384 PMCID: PMC11200556 DOI: 10.3390/biomedicines12061177] [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: 04/03/2024] [Revised: 05/18/2024] [Accepted: 05/23/2024] [Indexed: 06/28/2024] Open
Abstract
Intradialytic hypotension (IDH) is a severe complication of hemodialysis (HD) with a significant impact on morbidity and mortality. In this study, we used a wearable device for the continuous monitoring of hemodynamic vitals to detect hemodynamic changes during HD and attempted to identify IDH. End-stage kidney disease patients were continuously monitored 15 min before starting the session and until 15 min after completion of the session, measuring heart rate (HR), noninvasive cuffless systolic and diastolic blood pressure (SBP and DBP), stroke volume (SV), cardiac output (CO), and systemic vascular resistance (SVR). Data were analyzed retrospectively and included comparing BP measured by the wearable devices (recorded continuously every 5 s) and the cuff-based devices. A total of 98 dialysis sessions were included in the final analysis, and IDH was identified in 22 sessions (22.5%). Both SBP and DBP were highly correlated (r > 0.62, p < 0.001 for all) between the wearable device and the cuff-based measurements. Based on the continuous monitoring, patients with IDH had earlier and more profound reductions in SBP and DBP during the HD treatment. In addition, nearly all of the advanced vitals differed between groups. Further studies should be conducted in order to fully understand the potential of noninvasive advanced continuous monitoring in the prediction and prevention of IDH events.
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Affiliation(s)
- Yotam Kolben
- Heart Institute, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (Y.K.); (S.A.); (P.M.); (D.N.)
| | - Ittamar Gork
- Department of Nephrology and Hypertension, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel;
| | - David Peled
- Department of Health Promotion, School of Public Health, Faculty of Medicine and Health, Sylvan Adams Sports Institute, Tel Aviv University, Tel Aviv 6997801, Israel; (D.P.); (Y.G.)
| | - Shani Amitay
- Heart Institute, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (Y.K.); (S.A.); (P.M.); (D.N.)
| | - Peleg Moshel
- Heart Institute, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (Y.K.); (S.A.); (P.M.); (D.N.)
| | - Nir Goldstein
- Biobeat Technologies Ltd., Petah Tikva 4937213, Israel; (N.G.); (A.B.I.); (M.F.); (M.T.)
| | - Arik Ben Ishay
- Biobeat Technologies Ltd., Petah Tikva 4937213, Israel; (N.G.); (A.B.I.); (M.F.); (M.T.)
| | - Meir Fons
- Biobeat Technologies Ltd., Petah Tikva 4937213, Israel; (N.G.); (A.B.I.); (M.F.); (M.T.)
| | - Michael Tabi
- Biobeat Technologies Ltd., Petah Tikva 4937213, Israel; (N.G.); (A.B.I.); (M.F.); (M.T.)
| | - Arik Eisenkraft
- Biobeat Technologies Ltd., Petah Tikva 4937213, Israel; (N.G.); (A.B.I.); (M.F.); (M.T.)
- Institute for Research in Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and the Israel Defense Force Medical Corps, Jerusalem 9112102, Israel
| | - Yftach Gepner
- Department of Health Promotion, School of Public Health, Faculty of Medicine and Health, Sylvan Adams Sports Institute, Tel Aviv University, Tel Aviv 6997801, Israel; (D.P.); (Y.G.)
| | - Dean Nachman
- Heart Institute, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (Y.K.); (S.A.); (P.M.); (D.N.)
- Institute for Research in Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and the Israel Defense Force Medical Corps, Jerusalem 9112102, Israel
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Mambelli E, Grandi F, Santoro A. Comparison of blood volume biofeedback hemodialysis and conventional hemodialysis on cardiovascular stability and blood pressure control in hemodialysis patients: a systematic review and meta-analysis of randomized controlled trials. J Nephrol 2024; 37:897-909. [PMID: 38530603 PMCID: PMC11239774 DOI: 10.1007/s40620-023-01844-0] [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: 08/24/2023] [Accepted: 11/18/2023] [Indexed: 03/28/2024]
Abstract
BACKGROUND Despite the improvements in hemodialysis (HD) technology, 20-30% of sessions are still complicated by hypotension or hypotension-related symptoms. Biofeedback systems have proven to reduce the occurrence of such events, but no conclusive findings can lead to wider adoption of these systems. We conducted this systematic review and meta-analysis of randomized clinical trials to establish whether the use of blood volume tracking systems compared to conventional hemodialysis (C-HD) reduces the occurrence of intradialytic hypotension. METHODS The PRISMA guidelines were used to carry out this systematic review. Randomized clinical trials that evaluated the incidence of intradialytic hypotension during C-HD and blood volume tracking-HD were searched in the current literature. PROSPERO registration number: CRD42023426328. RESULTS Ninety-seven randomized clinical trials were retrieved. Nine studies, including 347 participants and 13,274 HD treatments were considered eligible for this systematic review. The results showed that the use of biofeedback systems reduces the risk of intradialytic hypotension (log odds ratio = 0.63, p = 0.03) in hypotension-prone patients (log odds ratio = 0.54, p = 0.04). When analysis was limited to fluid overloaded or hypertensive patients, it did not show the same effect (log odds ratio = 0.79, p = 0.38). No correlation was found in systolic blood pressure drop during dialysis and in post-dialysis blood pressure. CONCLUSIONS The use of blood volume tracking systems may be effective in reducing the incidence of intradialytic hypotension and allowing for easier attainment of the patients' ideal dry body weight. New studies to examine the long-term effects of the use of blood volume tracking systems on real hard endpoints are needed.
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Affiliation(s)
- Emanuele Mambelli
- Nephrology and Dialysis Unit, AUSL Romagna - Ospedale Infermi, Rimini, Italy
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10
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Pelusio C, Endres P, Neyra JA, Allegretti AS. Renal Replacement Therapy in Cirrhosis: A Contemporary Review. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:133-138. [PMID: 38649217 PMCID: PMC11103613 DOI: 10.1053/j.akdh.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 12/20/2023] [Accepted: 01/02/2024] [Indexed: 04/25/2024]
Abstract
Acute kidney injury is a common complication of decompensated cirrhosis, frequently requires hospitalization, and carries a high short-term mortality. This population experiences several characteristic types of acute kidney injury: hypovolemic-mediated (prerenal), ischemic/nephrotoxic-mediated (acute-tubular necrosis), and hepatorenal syndrome. Prerenal acute kidney injury is treated with volume resuscitation. Acute-tubular necrosis is treated by optimizing perfusion pressure and discontinuing the offending agent. Hepatorenal syndrome, a unique physiology of decreased effective arterial circulation leading to renal vasoconstriction and ultimately acute kidney injury, is treated with plasma expansion with albumin and splanchnic vasoconstrictors such as terlipressin or norepinephrine. Common acute stressors such as bleeding, infection, and volume depletion often contribute to multifactorial acute kidney injury. Even with optimal medical management, many clinicians are faced with the challenge of initiating renal replacement therapy in these patients. This article reviews the epidemiology, indications, and complex considerations of renal replacement therapy for acute kidney injury in decompensated cirrhosis.
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Affiliation(s)
- Caterina Pelusio
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy; Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Paul Endres
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA.
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11
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Oliveira NDJ, Oliveira AA, Costa SM, Pirôpo US, Teles MF, Freitas VPD, Souza DAD, Pereira R. Comparison of Heart Autonomic Control between Hemodynamically Stable and Unstable Patients during Hemodialysis Sessions: A Bayesian Approach. ENTROPY (BASEL, SWITZERLAND) 2023; 25:883. [PMID: 37372226 DOI: 10.3390/e25060883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/26/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023]
Abstract
Intradialytic hypotension is a common complication during hemodialysis sessions. The analysis of successive RR interval variability using nonlinear methods represents a promising tool for evaluating the cardiovascular response to acute volemic changes. Thus, the present study aims to compare the variability of successive RR intervals between hemodynamically stable (HS) and unstable (HU) patients during a hemodialysis session, through linear and nonlinear methods. Forty-six chronic kidney disease patients volunteered in this study. Successive RR intervals and blood pressures were recorded throughout the hemodialysis session. Hemodynamic stability was defined based on the delta of systolic blood pressure (higher SBP-lower SBP). The cutoff for hemodynamic stability was defined as 30 mm Hg, and patients were stratified as: HS ([n = 21]: ≤29.9 mm Hg) or HU ([n = 25]: ≥30 mm Hg). Linear methods (low-frequency [LFnu] and high-frequency [HFnu] spectra) and nonlinear methods (multiscale entropy [MSE] for Scales 1-20, and fuzzy entropy) were applied. The area under the MSE curve at Scales 1-5 (MSE1-5), 6-20 (MSE6-20), and 1-20 (MSE1-20) were also used as nonlinear parameters. Frequentist and Bayesian inferences were applied to compare HS and HU patients. The HS patients exhibited a significantly higher LFnu and lower HFnu. For MSE parameters, Scales 3-20 were significantly higher, as well as MSE1-5, MSE6-20, and MSE1-20 in HS, when compared to HU patients (p < 0.05). Regarding Bayesian inference, the spectral parameters demonstrated an anecdotal (65.9%) posterior probability favoring the alternative hypothesis, while MSE exhibited moderate to very strong probability (79.4 to 96.3%) at Scales 3-20, and MSE1-5, MSE6-20, and MSE1-20. HS patients exhibited a higher heart-rate complexity than HU patients. In addition, the MSE demonstrated a greater potential than spectral methods to differentiate variability patterns in successive RR intervals.
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Affiliation(s)
- Natália de Jesus Oliveira
- Integrative Physiology Research Center, Department of Biological Sciences, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
- Research Group in Neuromuscular Physiology, Department of Biological Sciences, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
- Medicine School, Universidade Estadual Do Sudoeste da Bahia (UESB), Jequie 45210-506, BA, Brazil
| | - Alinne Alves Oliveira
- Integrative Physiology Research Center, Department of Biological Sciences, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
- Research Group in Neuromuscular Physiology, Department of Biological Sciences, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
- Postgraduate Program in Nursing & Health, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
| | - Silvania Moraes Costa
- Integrative Physiology Research Center, Department of Biological Sciences, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
- Research Group in Neuromuscular Physiology, Department of Biological Sciences, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
- Postgraduate Program in Nursing & Health, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
| | - Uanderson Silva Pirôpo
- Integrative Physiology Research Center, Department of Biological Sciences, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
- Research Group in Neuromuscular Physiology, Department of Biological Sciences, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
- Postgraduate Program in Nursing & Health, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
| | - Mauro Fernandes Teles
- Integrative Physiology Research Center, Department of Biological Sciences, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
- Postgraduate Program in Nursing & Health, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
- Faculdade Santo Agostinho (FASA), Vitória da Conquista 45028-100, BA, Brazil
| | - Verônica Porto de Freitas
- Integrative Physiology Research Center, Department of Biological Sciences, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
- Research Group in Neuromuscular Physiology, Department of Biological Sciences, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
- Postgraduate Program in Nursing & Health, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
| | - Dieslley Amorim de Souza
- Postgraduate Program in Nursing & Health, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
| | - Rafael Pereira
- Integrative Physiology Research Center, Department of Biological Sciences, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
- Research Group in Neuromuscular Physiology, Department of Biological Sciences, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
- Medicine School, Universidade Estadual Do Sudoeste da Bahia (UESB), Jequie 45210-506, BA, Brazil
- Postgraduate Program in Nursing & Health, Universidade Estadual do Sudoeste da Bahia, Jequie 45210-506, BA, Brazil
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12
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N Ngankem LSQ, Larizza C, Nocera A, Rombolà G, Quaglini S, Bellazzi R, Costantino ML, Casagrande G. A comparative study of the definitions of intradialytic hypotension correlated with increased mortality to identify universal predictors. Int J Med Inform 2023; 173:104975. [PMID: 36905746 DOI: 10.1016/j.ijmedinf.2022.104975] [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: 03/09/2022] [Revised: 05/28/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022]
Abstract
Intradialytic hypotension (IDH) is a common complication in patients undergoing hemodialysis therapy. No consensus on the definition of intradialytic hypotension has been established so far. As a result, coherent and consistent evaluation of its effects and causes is difficult. Some studies have highlighted existing correlations between certain definitions of IDH and the risk of mortality for the patients. This work is mainly focused on these definitions. Our aim is to understand if different IDH definitions, all correlated with increased mortality risk, catch the same onset mechanisms or dynamics. To check whether the dynamics captured by these definitions are similar, we performed analyses of the incidence, of the IDH event onset timing, and checked whether there were similarities between the definitions in those aspects. We evaluated how these definitions overlap with each other and we evaluated which common factors could allow identifying patients at risk of IDH at the beginning of a dialysis session. The definitions of IDH we analyzed through statistical and machine learning approaches, showed a variable incidence on the HD sessions and had different onset time. We found that the set of parameters relevant for the prediction of the IDH was not always the same for the definitions considered. However, it can be observed that some predictors, such as the presence of comorbidities such as diabetes or heart disease, and a low pre-dialysis diastolic blood pressure, have shown universal relevance in highlighting an increased risk of IDH during the treatment. Among those parameters, the one that showed a major importance is the diabetes status of the patients. Diabetes or heart disease presence are permanent risk factors pointing out an increased IDH risk during the treatments, while, pre-dialysis diastolic blood pressure is instead a parameter that can change at every session and should be used to evaluate the specific risk to develop IDH for each session. The identified parameters could be used in the future to train more complex prediction models.
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Affiliation(s)
| | - Cristiana Larizza
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Italy.
| | - Antonino Nocera
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Italy.
| | - Giuseppe Rombolà
- ASST-SetteLaghi-Varese, Nephrology Dialysis and Kidney Trasplant Unit, Italy.
| | - Silvana Quaglini
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Italy.
| | - Riccardo Bellazzi
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Italy.
| | - Maria Laura Costantino
- Department of Chemistry, Materials and Chemical Engineering, Polytechnic University of Milan, Italy.
| | - Giustina Casagrande
- Department of Chemistry, Materials and Chemical Engineering, Polytechnic University of Milan, Italy.
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Circumferential Strain as a Marker of Vessel Reactivity in Patients with Intradialytic Hypotension. Medicina (B Aires) 2023; 59:medicina59010102. [PMID: 36676726 PMCID: PMC9865043 DOI: 10.3390/medicina59010102] [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: 11/14/2022] [Revised: 12/21/2022] [Accepted: 12/24/2022] [Indexed: 01/03/2023] Open
Abstract
Background and Objectives: Intradialytic hypotension (IDH) complicates 4 to 39.9% of hemodialysis (HD) sessions. Vessels' reactivity disturbances may be responsible for this complication. Two-dimensional speckle tracking is used to assess arterial circumferential strain (CS) as a marker of the effectiveness of the cardiovascular response to the reduction of circulating plasma. Materials and Methods: The common carotid artery (CCA) and common iliac artery (CIA) CSs were recorded using ultrasonography in 68 chronically dialyzed patients before and after one HD session. Results: In patients with IDH episodes (n = 26), the CCA-CS was significantly lower both before (6.28 ± 2.34 vs. 4.63 ± 1.74 p = 0.003) and after HD (5.00 (3.53-6.78) vs. 3.79 ± 1.47 p = 0.010) than it was in patients without this complication. No relationship was observed between CIA-CS and IDH. IDH patients had a significantly higher UF rate; however, they did not differ compared to complication-free patients either in anthropometric or laboratory parameters. Conclusions: Patients with IDH were characterized by lower pre- and post-HD circumferential strain of the common carotid artery. The lower CCA-CS showed that impaired vascular reactivity is one of the most important risk factors for this complication's occurrence.
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14
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Mambelli E, Rigotti A. A novel double parameters based biofeedback system to prevent intradialytic hypotension in clinical practice: Case report. Int J Artif Organs 2022; 45:966-970. [PMID: 36151712 DOI: 10.1177/03913988221124620] [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] [Indexed: 11/15/2022]
Abstract
Intradialytic hypotension (IDH) still represents the main complication during dialysis treatment. Patient's discomfort, reduced dialysis efficiency, reduced treatment time are only some of the main problems that could derive from the need to stop or temporarily interrupt the treatment because of IDH. Up to now, different types of treatment (HDF, HF, or AFB) have been considered to prevent IDH as well as the use of biofeedback systems (Blood Volume Monitoring, Temperature control, Sodium profiling, Blood Pressure monitoring). Recently a new biofeedback system (Biologic Fusion®) controlling simultaneously blood pressure (BP) and relative blood volume changes (RBV) has been developed to prevent IDH. This system runs according to fuzzy logic. We describe how this system works and to a better understanding, we report a clinical case of a patient with frequent IDH treated with the use of this system.
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Affiliation(s)
- Emanuele Mambelli
- U.O. Nefrologia e Dialisi, Ospedale Infermi-Rimini-AUSL della Romagna, Italy
| | - Angelo Rigotti
- U.O. Nefrologia e Dialisi, Ospedale Infermi-Rimini-AUSL della Romagna, Italy
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15
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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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Bae TW, Kim MS, Park JW, Kwon KK, Kim KH. Multilayer Perceptron-Based Real-Time Intradialytic Hypotension Prediction Using Patient Baseline Information and Heart-Rate Variation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10373. [PMID: 36012006 PMCID: PMC9408052 DOI: 10.3390/ijerph191610373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/15/2022] [Accepted: 08/18/2022] [Indexed: 06/15/2023]
Abstract
Intradialytic hypotension (IDH) is a common side effect that occurs during hemodialysis and poses a great risk for dialysis patients. Many studies have been conducted so far to predict IDH, but most of these could not be applied in real-time because they used only underlying patient information or static patient disease information. In this study, we propose a multilayer perceptron (MP)-based IDH prediction model using heart rate (HR) information corresponding to time-series information and static data of patients. This study aimed to validate whether HR differences and HR slope information affect real-time IDH prediction in patients undergoing hemodialysis. Clinical data were collected from 80 hemodialysis patients from 9 September to 17 October 2020, in the artificial kidney room at Yeungnam University Medical Center (YUMC), Daegu, South Korea. The patients typically underwent hemodialysis 12 times during this period, 1 to 2 h per session. Therefore, the HR difference and HR slope information within up to 1 h before IDH occurrence were used as time-series input data for the MP model. Among the MP models using the number and data length of different hidden layers, the model using 60 min of data before the occurrence of two layers and IDH showed maximum performance, with an accuracy of 81.5%, a true positive rate of 73.8%, and positive predictive value of 87.3%. This study aimed to predict IDH in real-time by continuously supplying HR information to MP models along with static data such as age, diabetes, hypertension, and ultrafiltration. The current MP model was implemented using relatively limited parameters; however, its performance may be further improved by adding additional parameters in the future, further enabling real-time IDH prediction to play a supporting role for medical staff.
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Affiliation(s)
- Tae Wuk Bae
- Daegu-Gyeongbuk Research Center, Electronics and Telecommunications Research Institute, Daegu 42994, Korea
| | - Min Seong Kim
- Daegu-Gyeongbuk Research Center, Electronics and Telecommunications Research Institute, Daegu 42994, Korea
| | - Jong Won Park
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu 42415, Korea
| | - Kee Koo Kwon
- Daegu-Gyeongbuk Research Center, Electronics and Telecommunications Research Institute, Daegu 42994, Korea
| | - Kyu Hyung Kim
- Daegu-Gyeongbuk Research Center, Electronics and Telecommunications Research Institute, Daegu 42994, Korea
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Chewcharat A, Chewcharat P, Liu W, Cellini J, Phipps EA, Melendez Young JA, Nigwekar SU. The effect of levocarnitine supplementation on dialysis-related hypotension: A systematic review, meta-analysis, and trial sequential analysis. PLoS One 2022; 17:e0271307. [PMID: 35834513 PMCID: PMC9282471 DOI: 10.1371/journal.pone.0271307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/27/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Dialysis patients have been shown to have low serum carnitine due to poor nutrition, deprivation of endogenous synthesis from kidneys, and removal by hemodialysis. Carnitine deficiency leads to impaired cardiac function and dialysis-related hypotension which are associated with increased mortality. Supplementing with levocarnitine among hemodialysis patients may diminish incidence of intradialytic hypotension. Data on this topic, however, lacks consensus. METHODS We conducted electronic searches in PubMed, Embase and Cochrane Central Register of Controlled Trials from January 1960 to 19th November 2021 to identify randomized controlled studies (RCTs), which examined the effects of oral or intravenous levocarnitine (L-carnitine) on dialysis-related hypotension among hemodialysis patients. The secondary outcome was muscle cramps. Study results were pooled and analyzed utilizing the random-effects model. Trial sequential analysis (TSA) was performed to assess the strength of current evidence. RESULTS Eight trials with 224 participants were included in our meta-analysis. Compared to control group, L-carnitine reduced the incidence of dialysis-related hypotension among hemodialysis patients (pooled OR = 0.26, 95% CI [0.10-0.72], p = 0.01, I2 = 76.0%). TSA demonstrated that the evidence was sufficient to conclude the finding. Five studies with 147 participants showed a reduction in the incidence of muscle cramps with L-carnitine group (pooled OR = 0.22, 95% CI [0.06-0.81], p = 0.02, I2 = 74.7%). However, TSA suggested that further high-quality studies were required. Subgroup analysis on the route of supplementation revealed that only oral but not intravenous L-carnitine significantly reduced dialysis-related hypotension. Regarding dose and duration of L-carnitine supplementation, the dose > 4,200 mg/week and duration of at least 12 weeks appeared to prevent dialysis-related hypotension. CONCLUSION Supplementing oral L-carnitine for at least three months above 4,200 mg/week helps prevent dialysis-related hypotension. L-carnitine supplementation may ameliorate muscle cramps. Further well-powered studies are required to conclude this benefit.
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Affiliation(s)
- Api Chewcharat
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, United States of America
| | - Pol Chewcharat
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Weitao Liu
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, United States of America
| | - Jacqueline Cellini
- Countway Library, Harvard Medical School, Boston, MA, United States of America
| | - Elizabeth A. Phipps
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, United States of America
| | - Jill A. Melendez Young
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, United States of America
| | - Sagar U. Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
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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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Kim KY, Park HS, Kim JS, Ahn SY, Ko GJ, Kwon YJ, Kim JE. Comparison of intradialytic blood pressure metrics as predictors of all-cause mortality. Clin Kidney J 2021; 14:2600-2605. [PMID: 34950471 PMCID: PMC8690150 DOI: 10.1093/ckj/sfab124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/14/2021] [Indexed: 11/12/2022] Open
Abstract
Background Intradialytic hypotension (IDH) has been reported to be an important prognostic factor in hemodialysis patients. However, a standard definition of IDH has not yet been determined. Methods We retrospectively analyzed blood pressure (BP) metrics obtained during serial dialysis sessions over a 90-day period from a single dialysis center from 2016 to 2017. The mean values and the frequency of specific values of BP were analyzed as predictors of 3-year mortality. Results A total of 430 patients who underwent maintenance dialysis were included. The mean age was 63.3 ± 12.4 years and 58.6% were male. A low minimum systolic blood pressure (SBP) <110 mmHg during dialysis was significantly associated with increased all-cause mortality. The frequency of a minimum SBP <100 mmHg was the most significant predictor of 3-year mortality, with an area under the curve (AUC) of 0.722. Furthermore, the frequency of a minimum SBP <100 mmHg significantly increased the predictability of mortality when combined with the presence of other clinical factors including age, body mass index and vascular access type (AUC 0.786 vs. 0.835; p = 0.005). Conclusion Among the various intradialytic BP metrics, the frequency of a minimum SBP <100 mmHg is the most significant factor related to all-cause mortality. The guidelines for the management of blood pressure in dialysis patients should consider including a minimum SBP <100 mmHg as a definition for IDH.
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Affiliation(s)
- Ka Young Kim
- Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Hae Sang Park
- Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Jin Sun Kim
- Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Shin Young Ahn
- Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Gang Jee Ko
- Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Young Joo Kwon
- Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Ji Eun Kim
- Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
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20
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Yu J, Chen X, Li Y, Wang Y, Liu Z, Shen B, Teng J, Zou J, Ding X. High ultrafiltration rate induced intradialytic hypotension is a predictor for cardiac remodeling: a 5-year cohort study. Ren Fail 2021; 43:40-48. [PMID: 33307918 PMCID: PMC7745843 DOI: 10.1080/0886022x.2020.1853570] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Intradialytic-hypotension (IDH) is a common complication of hemodialysis. High ultrafiltration rate (UFR) might lead to IDH. However, the relationships between UFR, IDH, and cardiac remodeling among hemodialysis patients in the long-term have not been deeply explored. METHODS This retrospective cohort study collected clinical and echocardiographic data. Patients were enrolled from 1 January 2014 to 31 March 2014 and were followed-up for 5-year. Those who suffered from more than four hypotensive events during three months (10% of dialysis treatments) were defined as the IDH group. Subgroup analysis was done according to the UFR of 10 ml/h/kg. Associations between UFR, IDH, and alterations of cardiac structure/function were analyzed. RESULTS Among 209 patients, 96 were identified with IDH (45.9%). The survival rate of IDH patients was lower than that of no-IDH patients (65.5% vs. 81.4%, p = .005). In IDH group, decreased ejection fraction (EF), larger left atrium diameter index (LADI), and left ventricular mass index (LVMI) (p < .05) were observed at the end of the follow-up. In multivariate logistic model, the interaction between UFR and IDH was notably associated with LVMI variation (OR = 1.37). After adjusting covariates, UFR was still an independent risk factor of LVMI variation (OR = 1.52) in IDH group. In subsequent analysis, we divided patients according to UFR 10 ml/h/kg. For IDH-prone patients, decreased EF, larger LADI, and LVMI (p < .05) were observed at the end of the study only in high-UFR group. CONCLUSIONS UFR and IDH have interactions on cardiac remodeling. High ultrafiltration rate induced IDH is a predictor for cardiac remodeling in long-term follow-up.
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Affiliation(s)
- Jinbo Yu
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, P. R. China
- Shanghai Institute of Kidney Disease and Dialysis, Shanghai, P. R. China
- Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, P. R. China
| | - Xiaohong Chen
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, P. R. China
- Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, P. R. China
| | - Yang Li
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, P. R. China
- Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, P. R. China
| | - Yaqiong Wang
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, P. R. China
- Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, P. R. China
| | - Zhonghua Liu
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, P. R. China
- Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, P. R. China
| | - Bo Shen
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, P. R. China
- Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, P. R. China
| | - Jie Teng
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, P. R. China
- Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, P. R. China
| | - Jianzhou Zou
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, P. R. China
- Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, P. R. China
| | - Xiaoqiang Ding
- Division of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, P. R. China
- Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, P. R. China
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21
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Chang TI, Tatoian ET, Montez-Rath ME, Chertow GM. Timing of Antihypertensive Medications on Key Outcomes in Hemodialysis: A Cluster Randomized Trial. KIDNEY360 2021; 2:1752-1760. [PMID: 35373003 PMCID: PMC8785843 DOI: 10.34067/kid.0001922021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/30/2021] [Indexed: 02/04/2023]
Abstract
Background We conducted this study to examine the effect of taking versus holding BP medications before hemodialysis on intradialytic hypotension (IDH). Methods In this cluster randomized trial, each dialysis unit was randomly designated as TAKE or HOLD units. Participants within a TAKE unit were instructed to take all BP medications as prescribed, whereas participants within a HOLD unit were instructed to hold medications dosed more than once daily before hemodialysis. The intervention lasted for 4 weeks. We hypothesized that TAKE would be noninferior to HOLD on the primary outcome of asymptomatic IDH, defined as ≥30% of sessions with nadir systolic BP <90 mm Hg and on the following secondary outcomes: uncontrolled hypertension (predialysis systolic BP >160 mm Hg), failure to achieve dry weight, and shortened dialysis sessions. Results We randomized 10 dialysis units in a 1:1 ratio to TAKE or HOLD, which included 65 participants in TAKE and 66 participants in HOLD. We did not show that TAKE was noninferior to HOLD for the primary IDH outcome (mean unadjusted difference of 8%; 95% CI, -3% to 19%). TAKE was superior to HOLD for the outcome of uncontrolled hypertension (mean unadjusted difference of -15%, 95% CI, -28% to -1%). TAKE was noninferior to HOLD for the outcomes of failure to achieve dry weight and shortened dialysis sessions. Conclusions In this cluster randomized trial that randomized patients to either taking or holding BP medications before hemodialysis, a strategy of taking BP medications dosed more than once daily was not noninferior to holding BP medications for the primary outcome of IDH, but did reduce the occurrence of uncontrolled hypertension. Whether any potential benefit of holding BP medications on reducing IDH is offset by any potential harm related to higher predialysis BP remains to be seen.
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Affiliation(s)
- Tara I. Chang
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Emily Tamar Tatoian
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Maria E. Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Glenn M. Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
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22
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Liu YS, Yang CY, Chiu PF, Lin HC, Lo CC, Lai ASH, Chang CC, Lee OKS. Machine Learning Analysis of Time-Dependent Features for Predicting Adverse Events During Hemodialysis Therapy: Model Development and Validation Study. J Med Internet Res 2021; 23:e27098. [PMID: 34491204 PMCID: PMC8456349 DOI: 10.2196/27098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 07/10/2021] [Accepted: 08/12/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Hemodialysis (HD) therapy is an indispensable tool used in critical care management. Patients undergoing HD are at risk for intradialytic adverse events, ranging from muscle cramps to cardiac arrest. So far, there is no effective HD device-integrated algorithm to assist medical staff in response to these adverse events a step earlier during HD. OBJECTIVE We aimed to develop machine learning algorithms to predict intradialytic adverse events in an unbiased manner. METHODS Three-month dialysis and physiological time-series data were collected from all patients who underwent maintenance HD therapy at a tertiary care referral center. Dialysis data were collected automatically by HD devices, and physiological data were recorded by medical staff. Intradialytic adverse events were documented by medical staff according to patient complaints. Features extracted from the time series data sets by linear and differential analyses were used for machine learning to predict adverse events during HD. RESULTS Time series dialysis data were collected during the 4-hour HD session in 108 patients who underwent maintenance HD therapy. There were a total of 4221 HD sessions, 406 of which involved at least one intradialytic adverse event. Models were built by classification algorithms and evaluated by four-fold cross-validation. The developed algorithm predicted overall intradialytic adverse events, with an area under the curve (AUC) of 0.83, sensitivity of 0.53, and specificity of 0.96. The algorithm also predicted muscle cramps, with an AUC of 0.85, and blood pressure elevation, with an AUC of 0.93. In addition, the model built based on ultrafiltration-unrelated features predicted all types of adverse events, with an AUC of 0.81, indicating that ultrafiltration-unrelated factors also contribute to the onset of adverse events. CONCLUSIONS Our results demonstrated that algorithms combining linear and differential analyses with two-class classification machine learning can predict intradialytic adverse events in quasi-real time with high AUCs. Such a methodology implemented with local cloud computation and real-time optimization by personalized HD data could warn clinicians to take timely actions in advance.
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Affiliation(s)
- Yi-Shiuan Liu
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan.,Stem Cell Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Physiology and Pharmacology, Chang Gung University College of Medicine, Taoyuan, Taiwan.,Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chih-Yu Yang
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan.,Stem Cell Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Center for Intelligent Drug Systems and Smart Bio-devices, Hsinchu, Taiwan
| | - Ping-Fang Chiu
- Division of Nephrology, Department of Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Hui-Chu Lin
- Stem Cell Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chung-Chuan Lo
- Institute of Systems Neuroscience, National Tsing Hua University, Hsinchu, Taiwan
| | - Alan Szu-Han Lai
- Stem Cell Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-Chu Chang
- Department of Medicine, Kuang Tien General Hospital, Taichung, Taiwan.,Department of Nutrition, Hungkuang University, Taichung, Taiwan
| | - Oscar Kuang-Sheng Lee
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan.,Stem Cell Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan
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23
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Chen W, Wang F, Zhao Y, Zhang L, Chen Z, Dai M. Efficacy and safety of furosemide for prevention of intradialytic hypotension in haemodialysis patients: protocol for a multicentre randomised controlled trial. BMJ Open 2021; 11:e048015. [PMID: 34226226 PMCID: PMC8258570 DOI: 10.1136/bmjopen-2020-048015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Intradialytic hypotension (IDH) is a frequent and serious complication of maintaining haemodialysis (HD) patients and associated with subsequent cardiovascular events and higher mortality. Furosemide is commonly used in non-dialysis chronic kidney disease patients and can effectively manage the volume and blood pressure. However, these agents are often discontinued on initiation of dialysis. Two large observational studies have demonstrated that furosemide can lower the rate of IDH episodes. However, there is still no randomised controlled trial (RCT) to investigate the efficacy and safety of furosemide for prevention of IDH in HD patients. The purpose of this study was to assess the efficacy of furosemide in reducing IDH in HD patients with residual renal function. METHODS AND ANALYSIS A two-arm, parallel, multicente RCT will be conducted at 12 hospitals in China. An estimated sample of 560 HD patients will be recruited. Eligible patients will be randomly assigned to treatment group (patients receive oral furosemide 80 mg/day; after a 2-week treatment, if their urine volume is less than 400 mL/day, the dose of furosemide is adjusted to 160 mg/day) and blank control group via a central randomisation system using 1:1 ratio. The primary outcome is the occurrence of IDH. Outcome assessors and data analysts will be blinded and participants will be asked not to reveal their allocation to assessors. The outcome analyses will be performed both on the intention-to-treat, which includes all patients randomised, and per-protocol population, which includes eligible patients who adhere to the planned treatment and follow-ups. ETHICS AND DISSEMINATION The trial protocol has been approved by the Biomedical Research Ethics Committee of West China Hospital of Sichuan University (2019.385)Results will be presented at national and international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ChiCTR2000039724.
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Affiliation(s)
- Wenwen Chen
- Division of Nephrology, Kidney Research Institute, State Key Laboratory of Biotherapy and Cancer Center, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Fang Wang
- Department of Nephrology, West China Hospital, Sichuan University/ West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
| | - Yuliang Zhao
- Department of Nephrology, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Ling Zhang
- Department of Nephrology, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Zhiwen Chen
- Department of Nephrology, West China Hospital, Sichuan University/ West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
| | - Mingjin Dai
- Department of Nephrology, West China Hospital, Sichuan University/ West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
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24
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Fernandez-Prado R, Peña-Esparragoza JK, Santos-Sánchez-Rey B, Pereira M, Avello A, Gomá-Garcés E, González-Rivera M, González-Martin G, Gracia-Iguacel C, Mahillo I, Ortiz A, González-Parra E. Ultrafiltration rate adjusted to body weight and mortality in hemodialysis patients. Nefrologia 2021; 41:426-435. [PMID: 36165111 DOI: 10.1016/j.nefroe.2021.10.005] [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: 06/15/2020] [Accepted: 10/17/2020] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND AND AIMS Mortality among hemodialysis patients remains high. An elevated ultrafiltration rate adjusted by weight (UFR/W) has been associated with hypotension and higher risk of death and/or cardiovascular events. METHODS We evaluated the association between UFR/W and mortality in 215 hemodialysis patients. The mean follow-up was 28 ± 6.12 months. We collected patients' baseline characteristics and mean UFR/W throughout the follow-up. RESULTS Mean UFR/W was 9.0 ± 2,4 and tertiles 7.1 y 10.1 mL/kg/h. We divided our population according to the percentage of sessions with UFR/W above the limits described in the literature associated with increased mortality (10.0 ml/kg/h and 13.0 mL/kg/h). Patients with higher UFR/W were younger, with higher interdialytic weight gain and weight reduction percentage but lower dry, pre and post dialysis weight. Throughout the follow-up, 46 (21.4%) patients died, the majority over 70 years old, diabetic or with cardiovascular disease. There were neither differences regarding mortality between groups nor differences in UFR/W among patients who died and those who did not. Contrary to previous studies, we did not find an association between UFR/W and mortality, maybe due to a higher prevalence in the use of cardiovascular protection drugs and lower UFR/W. CONCLUSIONS The highest UFR/W were observed in younger patients with lower weight and were not associated with an increased mortality.
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25
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Fernandez-Prado R, Peña-Esparragoza JK, Santos-Sánchez-Rey B, Pereira M, Avello A, Gomá-Garcés E, González-Rivera M, González-Martin G, Gracia-Iguacel C, Mahillo I, Ortiz A, González-Parra E. Ultrafiltration rate adjusted to body weight and mortality in hemodialysis patients. Nefrologia 2021. [PMID: 33663812 DOI: 10.1016/j.nefro.2020.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND AIMS Mortality among hemodialysis patients remains high. An elevated ultrafiltration rate adjusted by weight (UFR/W) has been associated with hypotension and higher risk of death and/or cardiovascular events. METHODS We evaluated the association between UFR/W and mortality in 215 hemodialysis patients. The mean follow-up was 28 ± 6.12 months. We collected patientś baseline characteristics and mean UFR/W throughout the follow-up. RESULTS Mean UFR/W was 9.0 ± 2,4 and tertiles 7.1 y 10.1 mL/kg/h. We divided our population according to the percentage of sessions with UFR/W above the limits described in the literature associated with increased mortality (10.0 mL/kg/h and 13.0 mL/kg/h). Patients with higher UFR/W were younger, with higher interdialytic weight gain and weight reduction percentage but lower dry, pre and post dialysis weight. Throughout the follow-up, 46 (21.4%) patients died, the majority over 70 years old, diabetic or with cardiovascular disease. There were neither differences regarding mortality between groups nor differences in UFR/W among patients who died and those who did not. Contrary to previous studies, we did not find an association between UFR/W and mortality, maybe due to a higher prevalence in the use of cardiovascular protection drugs and lower UFR/W. CONCLUSIONS The highest UFR/W were observed in younger patients with lower weight and were not associated with an increased mortality.
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26
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Delma S, Coulibaly G, Lengani HYA, Rouamba N, Bonzi YJ. [Prevalence and risk factors associated with intradialytic hypotension in Sub-Saharan Africa: The case of Burkina Faso]. Ann Cardiol Angeiol (Paris) 2021; 71:27-31. [PMID: 33637316 DOI: 10.1016/j.ancard.2021.01.002] [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: 11/27/2020] [Accepted: 01/28/2021] [Indexed: 10/22/2022]
Abstract
AIM The aim of our study was to determine the prevalence and factors associated with intradialytic hypotension in our cohort of chronic hemodialysis patients. METHODS This was a prospective monocentric study over a six-month period. Intradialytic hypotension was defined as a decrease in systolic blood pressure ≥ 20mmHg or a decrease in mean arterial pressure of 10mmHg associated with clinical events and the need for nursing interventions. The groups were compared using univariate analysis of variance. RESULTS We included 48 patients and counted 3014 hemodialysis sessions. The mean age was 44.7±15 years. The prevalence of intradialytic hypotension was 12.4%, with cramps 20 (41.7%) as the main symptom. Factors associated with frequent intradialytic hypotension compared to the groups without intradialytic hypotension and with infrequent intradialytic hypotension were age (61±13 years, p=0.018), diabetes (33.3%, p=0.019), high body mass index (27, 3±7.8kg/m2, p=0.002), interdialytic weight gain ≥ 5% of baseline weight (66.7%, p=0.033), hourly ultrafiltration (800±275ml/h, p=0.037) and perdialytic feeding (33.3%, p=0.016). Low pre-dialysis diastolic blood pressure (72±13mmHg, p=0.012) and high baseline weight (73.9±17.5kg, p=0.028) were associated with frequent versus infrequent intradialytic hypotension. CONCLUSION Intradialytic hypotension is common in our context. Its prevention in at-risk patients is critical to reducing morbidity and mortality and improving quality of life.
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Affiliation(s)
- S Delma
- Service de médecine et de spécialités médicales, centre hospitalier universitaire de Tengandogo, Ouagadougou, Burkina Faso; Service de néphrologie, centre hospitalier universitaire Yalgado Ouedraogo, Ouagadougou, Burkina Faso.
| | - G Coulibaly
- Service de néphrologie, centre hospitalier universitaire Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - H Y A Lengani
- Service de médecine et de spécialités médicales, centre hospitalier universitaire de Tengandogo, Ouagadougou, Burkina Faso
| | - N Rouamba
- Service de médecine et de spécialités médicales, centre hospitalier universitaire de Tengandogo, Ouagadougou, Burkina Faso
| | - Y J Bonzi
- Service de néphrologie, centre hospitalier universitaire Yalgado Ouedraogo, Ouagadougou, Burkina Faso
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27
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Ibrahim MAA, ElHakim IZ, Soliman D, Mubarak MA, Said RM. Online hemodiafilteration use in children: a single center experience with a twist. BMC Nephrol 2020; 21:306. [PMID: 32723294 PMCID: PMC7388526 DOI: 10.1186/s12882-020-01957-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/15/2020] [Indexed: 11/10/2022] Open
Abstract
Background Haemodiafilteration (HDF) is a promising new modality of renal replacement therapy (RRT). It is an improvement in the quality of hemodialysis (HD) and thus in the quality of patients’lives. The main obstacle to using HDF is the cost, especially in developing countries. The purpose of this study was to evaluate the benefits of incorporating HDF with different regimens in the treatment of children with end stage renal disease (ESRD). Methods Thirty-four children with ESRD on regular HD in Pediatric Dialysis Unit, Children’s Hospital, Ain Shams University were followed up in 2 phases: initial phase (all patients: HD thrice weekly for 3 months) and second phase, patients were randomized into 2 groups, HDF group and HD group, the former was subdivided into once and twice weekly HDF subgroups. Evaluation using history, clinical and laboratory parameters at 0, 3, 9 and 18 months was carried out. Results On short term, we found that the HDF group was significantly superior to HD group regarding all clinical and laboratory parameters. Also, twice HDF subgroup was significantly superior to once HDF subgroup. This was confirmed on long term follow up, but the once HDF proved comparable to twice subgroup. Conclusions Incorporating online hemodiafilteration (OL-HDF) in the RRT of children was beneficial in most of the clinical and laboratory parameters measured. It’s not all or non; OL-HDF, even once a week, can improve outcomes of HD without significantly affecting the cost.
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Affiliation(s)
- Magid A A Ibrahim
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ihab Z ElHakim
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Dina Soliman
- Department of Clinical Pathology & Immunology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Muhammad A Mubarak
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ragia M Said
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
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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: 97] [Impact Index Per Article: 19.4] [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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Alvis BD, Polcz M, Miles M, Wright D, Shwetar M, Leisy P, Forbes R, Fissell R, Whitfield J, Eagle S, Brophy C, Hocking K. Non-invasive venous waveform analysis (NIVA) for volume assessment in patients undergoing hemodialysis: an observational study. BMC Nephrol 2020; 21:194. [PMID: 32448178 PMCID: PMC7245891 DOI: 10.1186/s12882-020-01845-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/08/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Accurate assessment of volume status to direct dialysis remains a clinical challenge. Despite current attempts at volume-directed dialysis, inadequate dialysis and intradialytic hypotension (IDH) are common occurrences. Peripheral venous waveform analysis has recently been developed as a method to accurately determine intravascular volume status through algorithmic quantification of changes in the waveform that occur at different volume states. A noninvasive method to capture peripheral venous signals is described (Non-Invasive Venous waveform Analysis, NIVA). The objective of this proof-of-concept study was to characterize changes in NIVA signal with dialysis. We hypothesized that there would be a change in signal after dialysis and that the rate of intradialytic change in signal would be predictive of IDH. METHODS Fifty subjects undergoing inpatient hemodialysis were enrolled. A 10-mm piezoelectric sensor was secured to the middle volar aspect of the wrist on the extremity opposite to the access site. Signals were obtained fifteen minutes before, throughout, and up to fifteen minutes after hemodialysis. Waveforms were analyzed after a fast Fourier transformation and identification of the frequencies corresponding to the cardiac rate, with a NIVA value generated based on the weighted powers of these frequencies. RESULTS Adequate quality (signal to noise ratio > 20) signals pre- and post- dialysis were obtained in 38 patients (76%). NIVA values were significantly lower at the end of dialysis compared to pre-dialysis levels (1.203 vs 0.868, p < 0.05, n = 38). Only 16 patients had adequate signals for analysis throughout dialysis, but in this small cohort the rate of change in NIVA value was predictive of IDH with a sensitivity of 80% and specificity of 100%. CONCLUSIONS This observational, proof-of-concept study using a NIVA prototype device suggests that NIVA represents a novel and non-invasive technique that with further development and improvements in signal quality may provide static and continuous measures of volume status to assist with volume directed dialysis and prevent intradialytic hypotension.
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Affiliation(s)
- Bret D. Alvis
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University Medical Center, 422 MAB, 1211 21st Ave South, Nashville, TN 37212 USA
| | - Monica Polcz
- Vanderbilt University Medical Center, S111 Medical Center North, 21st Ave South, Medical Art Building 422, Nashville, TN 37212 USA
| | - Merrick Miles
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University Medical Center, 422 MAB, 1211 21st Ave South, Nashville, TN 37212 USA
| | - Donald Wright
- Vanderbilt University School of Medicine, 1161 21st Ave S # D3300, Nashville, TN 37232 USA
| | - Mohammad Shwetar
- Vanderbilt University School of Medicine, 1161 21st Ave S # D3300, Nashville, TN 37232 USA
| | - Phil Leisy
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University Medical Center, 422 MAB, 1211 21st Ave South, Nashville, TN 37212 USA
| | - Rachel Forbes
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, 1301 Medical Center Drive, Nashville, TN 37232 USA
| | - Rachel Fissell
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, 1161 21st Ave South, MCN S-3223, Nashville, TN 37232 USA
| | - Jon Whitfield
- Volumetrix, LLC, 2126 21st Ave South, Nashville, TN 37212 USA
| | - Susan Eagle
- Vanderbilt University Medical Center, S111 Medical Center North, 21st Ave South, Medical Art Building 422, Nashville, TN 37212 USA
| | - Colleen Brophy
- Vanderbilt University Medical Center, S111 Medical Center North, 21st Ave South, Medical Art Building 422, Nashville, TN 37212 USA
| | - Kyle Hocking
- Vanderbilt University Medical Center, S111 Medical Center North, 21st Ave South, Medical Art Building 422, Nashville, TN 37212 USA
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Marshall MR, Vandal AC, de Zoysa JR, Gabriel RS, Haloob IA, Hood CJ, Irvine JH, Matheson PJ, McGregor DOR, Rabindranath KS, Schollum JBW, Semple DJ, Xie Z, Ma TM, Sisk R, Dunlop JL. Effect of Low-Sodium versus Conventional Sodium Dialysate on Left Ventricular Mass in Home and Self-Care Satellite Facility Hemodialysis Patients: A Randomized Clinical Trial. J Am Soc Nephrol 2020; 31:1078-1091. [PMID: 32188697 PMCID: PMC7217404 DOI: 10.1681/asn.2019090877] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 02/19/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Fluid overload in patients undergoing hemodialysis contributes to cardiovascular morbidity and mortality. There is a global trend to lower dialysate sodium with the goal of reducing fluid overload. METHODS To investigate whether lower dialysate sodium during hemodialysis reduces left ventricular mass, we conducted a randomized trial in which patients received either low-sodium dialysate (135 mM) or conventional dialysate (140 mM) for 12 months. We included participants who were aged >18 years old, had a predialysis serum sodium ≥135 mM, and were receiving hemodialysis at home or a self-care satellite facility. Exclusion criteria included hemodialysis frequency >3.5 times per week and use of sodium profiling or hemodiafiltration. The main outcome was left ventricular mass index by cardiac magnetic resonance imaging. RESULTS The 99 participants had a median age of 51 years old; 67 were men, 31 had diabetes mellitus, and 59 had left ventricular hypertrophy. Over 12 months of follow-up, relative to control, a dialysate sodium concentration of 135 mmol/L did not change the left ventricular mass index, despite significant reductions at 6 and 12 months in interdialytic weight gain, in extracellular fluid volume, and in plasma B-type natriuretic peptide concentration (ratio of intervention to control). The intervention increased intradialytic hypotension (odds ratio [OR], 7.5; 95% confidence interval [95% CI], 1.1 to 49.8 at 6 months and OR, 3.6; 95% CI, 0.5 to 28.8 at 12 months). Five participants in the intervention arm could not complete the trial because of hypotension. We found no effect on health-related quality of life measures, perceived thirst or xerostomia, or dietary sodium intake. CONCLUSIONS Dialysate sodium of 135 mmol/L did not reduce left ventricular mass relative to control, despite improving fluid status. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER The Australian New Zealand Clinical Trials Registry, ACTRN12611000975998.
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Affiliation(s)
- Mark R Marshall
- Department of Renal Medicine, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand;
- School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Medical Affairs, Baxter Healthcare (Asia) Pte Ltd., Singapore
| | - Alain C Vandal
- Department of Statistics, Faculty of Science, University of Auckland, Auckland, New Zealand
| | - Janak R de Zoysa
- Department of Renal Medicine, North Shore Hospital, Waitemata District Health Board, Auckland, New Zealand
- Waitemata Clinical School, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ruvin S Gabriel
- Department of Cardiology, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
| | - Imad A Haloob
- Department of Renal Medicine, Bathurst Base Hospital, New South Wales, Bathurst, Australia
| | - Christopher J Hood
- Department of Renal Medicine, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
| | - John H Irvine
- Department of Nephrology, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Philip J Matheson
- Department of Nephrology, Wellington Hospital, Capital & Coast District Health Board, Wellington, New Zealand
| | - David O R McGregor
- Department of Nephrology, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Kannaiyan S Rabindranath
- Department of Nephrology, Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand
| | - John B W Schollum
- Nephrology Service, Dunedin Hospital, Southern District Health Board, Dunedin, New Zealand
| | - David J Semple
- Department of Renal Medicine, Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Zhengxiu Xie
- Middlemore Clinical Trials, Auckland, New Zealand; and
| | - Tian Min Ma
- Department of Renal Medicine, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand;
| | - Rose Sisk
- Division of Informatics, Imaging & Data Sciences, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Joanna L Dunlop
- Department of Renal Medicine, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
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Halle MP, Hilaire D, Francois KF, Denis T, Hermine F, Gloria AE. Intradialytic hypotension and associated factors among patients on maintenance hemodialysis: A single-center study in cameroon. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2020; 31:215-223. [PMID: 32129216 DOI: 10.4103/1319-2442.279944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Intradialytic hypotension (IDH), one of the most frequent acute complications of hemodialysis (HD), is associated with increased patient's morbidity and mortality. The aim of this study was to determine its prevalence and associated factors among patients on maintenance HD in Cameroon. This was a prospective longitudinal study carried out from June 20, to July 30, 2016 (5 weeks), including adult patients on HD >3 months at a tertiary hospital in Douala. During this period, patients were followed up at each HD session, and their blood pressure and occurrence of clinical events possibly related to IDH were recorded. In this study, IDH was defined as a decrease in systolic BP by >20 mm Hg or a decrease in mean arterial pressure by >10 mm Hg, associated to a clinical event. Logistic regression analysis was used to determine associated factors. We included 104 patients (69 males) with a mean age of 50.74 ± 15.18 years and a median duration on HD of 30.5 (interquartile range: 12.25-58.75) years. Hypertension 99/104 (95.2%) and diabetes 32/104 (30.8%) were the main comorbidities encountered. A total of 1032 HD sessions were followed up with an average of 9.88 ± 1.57 sessions per patient. IDH occurred in 11.6% of HD sessions. Associated factors were age, female sex, HIV infection, feeding during dialysis, and use of antihypertensive drug during or within 2 h before dialysis. The prevalence of IDH in our study was low. Associated factors were mainly related to patient's characteristics and comorbidities.
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Affiliation(s)
- Marie Patrice Halle
- Department of Clinical Sciences, Faculty of Medicine and Pharmaceutical Sciences, University of Douala; Department of Internal Medicine, Douala General Hospital, Douala, Cameroon
| | - Djantio Hilaire
- Department of Clinical Sciences, Higher Institute of Health Sciences, Université des Montagnes, Bangangte, Cameroon
| | - Kaze F Francois
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I; Department of Internal Medicine, Yaounde Teaching Hospital, Yaounde, Cameroon
| | - Teuwafeu Denis
- Department of Internal Medicine, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Fouda Hermine
- Department of Internal Medicine, Douala General Hospital, Douala; Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Ashuntantang E Gloria
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I; Department of Internal Medicine, Yaounde General Hospital, Yaounde, Cameroon
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Clarkson MJ, Brumby C, Fraser SF, McMahon LP, Bennett PN, Warmington SA. Hemodynamic and perceptual responses to blood flow-restricted exercise among patients undergoing dialysis. Am J Physiol Renal Physiol 2020; 318:F843-F850. [PMID: 32068463 DOI: 10.1152/ajprenal.00576.2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
End-stage kidney disease is associated with reduced exercise capacity, muscle atrophy, and impaired muscle function. While these may be improved with exercise, single modalities of exercise do not traditionally elicit improvements across all required physiological domains. Blood flow-restricted exercise may improve all of these physiological domains with low intensities traditionally considered insufficient for these adaptions. Investigation of this technique appeals, but is yet to be evaluated, in patients undergoing dialysis. With the use of a progressive crossover design, 10 satellite patients undergoing hemodialysis underwent three exercise conditions over 2 wk: two bouts (10 min) of unrestricted cycling during two consecutive hemodialysis sessions (condition 1), two bouts of cycling with blood flow restriction while off hemodialysis on 2 separate days (condition 2), and two bouts of cycling with blood flow restriction during two hemodialysis sessions (condition 3). Outcomes included hemodynamic responses (heart rate and blood pressure) throughout all sessions, participant-perceived exertion and discomfort on a Borg scale, and evaluation of ultrafiltration rates and dialysis adequacy (Kt/V) obtained post hoc. Hemodynamic responses were consistent regardless of condition. Significant increases in heart rate, systolic blood pressure, and mean arterial blood pressure (P < 0.05) were observed postexercise followed by a reduction in blood pressures during the 60-min recovery (12, 5, and 11 mmHg for systolic, diastolic, and mean arterial pressures, respectively). Blood pressures returned to predialysis ranges following the recovery period. Blood flow restriction did not affect ultrafiltration achieved or Kt/V. Hemodynamic safety and tolerability of blood flow restriction during aerobic exercise on hemodialysis is comparable to standard aerobic exercise.
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Affiliation(s)
- Matthew J Clarkson
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Victoria, Australia
| | - Catherine Brumby
- Department of Renal Medicine, Eastern Health Clinical School, Melbourne, Victoria, Australia
| | - Steve F Fraser
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Victoria, Australia
| | - Lawrence P McMahon
- Department of Renal Medicine, Eastern Health Clinical School, Melbourne, Victoria, Australia
| | - Paul N Bennett
- Medical and Clinical Affairs, Satellite Healthcare, Adelaide, South Australia, Australia.,School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
| | - Stuart A Warmington
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Victoria, Australia
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Lin CJ, Chen YY, Pan CF, Wu V, Wu CJ. Dataset supporting blood pressure prediction for the management of chronic hemodialysis. Sci Data 2019; 6:313. [PMID: 31819065 PMCID: PMC6901464 DOI: 10.1038/s41597-019-0319-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 11/12/2019] [Indexed: 11/09/2022] Open
Abstract
Hemodialysis (HD) is a treatment given to patients with renal failure. Notable treatment-related complications include hypotension, cramps, insufficient blood flow, and arrhythmia. Most complications are associated with unstable blood pressure during HD. Physicians are devoted to seeking solutions to prevent or lower the incidence of possible complications. With advances in technology, big data have been obtained in various medical fields. The accumulated dialysis records in each HD session can be gathered to obtain big HD data with the potential to assist HD staff in increasing patient wellbeing. We generated a large stream of HD parameters collected from dialysis equipment associated with the Vital Info Portal gateway and correlated with the demographic data stored in the hospital information system from each HD session. We expect that the application of HD big data will greatly assist HD staff in treating intradialytic hypotension, setting optimal dialysate parameters, and even developing an intelligent early-warning system as well as providing individualized suggestions regarding dialysis settings in the future.
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Affiliation(s)
- Cheng-Jui Lin
- Division of Nephrology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, New Taipei, Taiwan.,Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
| | - Ying-Ying Chen
- Division of Nephrology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chi-Feng Pan
- Division of Nephrology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Vincent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Jen Wu
- Division of Nephrology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan. .,Department of Medicine, Mackay Medical College, New Taipei, Taiwan. .,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan.
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Investigation of Acoustic Cardiographic Parameters before and after Hemodialysis. DISEASE MARKERS 2019; 2019:5270159. [PMID: 31781303 PMCID: PMC6874870 DOI: 10.1155/2019/5270159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 10/22/2019] [Indexed: 01/20/2023]
Abstract
Patients with end-stage renal disease are at an increased risk of cardiovascular diseases and associated mortality. Acoustic cardiography is a technique in which cardiac acoustic data is synchronized with electric information to detect and characterize heart sounds and detect heart failure early. The aim of this study was to investigate acoustic cardiographic parameters before and after hemodialysis (HD) and their correlations with ankle-brachial index (ABI), brachial-ankle pulse wave velocity (baPWV), and ratio of brachial preejection period to ejection time (bPEP/bET) obtained from an ABI-form device in HD patients. This study enrolled 162 HD patients between October 2016 and April 2018. Demographic, medical, and laboratory data were collected. Acoustic cardiography was performed before and after HD to assess parameters including third heart sound (S3), fourth heart sound (S4), systolic dysfunction index (SDI), electromechanical activation time (EMAT), and left ventricular systolic time (LVST). The mean age of the enrolled patients was 60.4 ± 10.9 years, and 86 (53.1%) patients were male. S4 (p < 0.001) and LVST (p < 0.001) significantly decreased after HD, but EMAT (p < 0.001) increased. Multivariate forward linear regression analysis showed that EMAT/LVST before HD was negatively associated with albumin (unstandardized coefficient β = ‐0.076; p = 0.004) and ABI (unstandardized coefficient β = ‐0.115; p = 0.011) and positively associated with bPEP/bET (unstandardized coefficient β = 0.278; p = 0.003). Screening HD patients with acoustic cardiography may help to identify patients at a high risk of malnutrition, peripheral artery disease, and left ventricular systolic dysfunction.
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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: 1.0] [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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Wang F, Wang Y, Tian Y, Zhang P, Chen J, Li J. Pattern recognition and prognostic analysis of longitudinal blood pressure records in hemodialysis treatment based on a convolutional neural network. J Biomed Inform 2019; 98:103271. [DOI: 10.1016/j.jbi.2019.103271] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 07/11/2019] [Accepted: 08/23/2019] [Indexed: 11/15/2022]
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Molin CZZD, Sakae TM, Schuelter-Trevisol F, Trevisol DJ. Effects of sertraline in the prevention of low blood pressure in patients undergoing hemodialysis. ACTA ACUST UNITED AC 2019; 41:492-500. [PMID: 31419272 PMCID: PMC6979582 DOI: 10.1590/2175-8239-jbn-2018-0189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 05/17/2019] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Intradialytic hypotension (IDH) is a major complication of hemodialysis, with a prevalence of about 25% during hemodialysis sessions, causing increased morbidity and mortality. OBJECTIVE To study the effects of sertraline to prevent IDH in hemodialysis patients. METHODS This was a double-blind, crossover clinical trial comparing the use of sertraline versus placebo to reduce intradialytic hypotension. RESULTS Sixteen patients completed the two phases of the study during a 12-week period. The IDH prevalence was 32%. A comparison between intradialytic interventions, intradialytic symptoms, and IDH episodes revealed no statistical difference in the reduction of IDH episodes (p = 0.207) between the two intervention groups. However, the risk of IDH interventions was 60% higher in the placebo group compared to the sertraline group, and the risk of IDH symptoms was 40% higher in the placebo group compared to the sertraline group. Survival analysis using Kaplan-Meier estimator supported the results of this study. Sertraline presented a number needed to treat (NNT) of 16.3 patients to prevent an episode from IDH intervention and 14.2 patients to prevent an episode from intradialytic symptoms. CONCLUSION This study suggests that the use of sertraline may be beneficial to reduce the number of symptoms and ID interventions, although there was no statistically significant difference in the blood pressure levels.
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Atallah R, Bauer F, Strohhöfer C, Haueisen J. A feedback system that combines monitoring of systolic blood pressure and relative blood volume in order to prevent hypotensive episodes during dialysis. Med Eng Phys 2019; 71:10-16. [PMID: 31326372 DOI: 10.1016/j.medengphy.2019.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/20/2019] [Accepted: 07/04/2019] [Indexed: 11/16/2022]
Abstract
Hypotensive Episodes (HEs) are one of the most common complications during dialysis. Occurrence of HEs can be reduced by applying physiological closed loop systems that monitor physiological parameter(s) and adjust dialysis related parameter(s). We developed a physiological closed loop control system (PCLCS) that monitors systolic blood pressure (sysBP) and relative blood volume (RBV) and calculates the net fluid removal (nfr) rate during dialysis. The performance of PCLCS was compared in the laboratory to a feedback system that monitors only RBV (BVFS). A laboratory test setup was developed to test the feedback systems. The test setup simulates nfr-rate and refilling of a patient's intravascular fluid. We studied the impact of the feedback systems PCLCS and BVFS on the number of HEs (sysBP < 90 mmHg), on the variance of sysBP and RBV, on pre to post sysBP and RBV and on the achievement of the nfr-volume. PCLCS allowed 80% less HEs than BVFS (p < 0.001). Variance of sysBP and RBV were reduced by 41.8% and by 52% (p < 0.001), respectively, when using PCLCS. There were no differences between pre to post sysBP nor between pre to post RBV when comparing PCLCS to BVFS. The nfr-volume was achieved by both feedback systems.
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Affiliation(s)
- Richard Atallah
- Department of Research and Development, B. Braun Avitum AG, Am Buschberg 1, 34212 Melsungen, Germany.
| | - Florian Bauer
- Department of Research and Development, B. Braun Avitum AG, Am Buschberg 1, 34212 Melsungen, Germany
| | - Christof Strohhöfer
- Department of Research and Development, B. Braun Avitum AG, Am Buschberg 1, 34212 Melsungen, Germany
| | - Jens Haueisen
- Institute of Biomedical Engineering and Informatics, Ilmenau University of Technology, Gustav-Kirchhoff-Straße 2, Ilmenau 98693, Germany
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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: 20] [Impact Index Per Article: 3.3] [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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Kuipers J, Verboom LM, Ipema KJR, Paans W, Krijnen WP, Gaillard CAJM, Westerhuis R, Franssen CFM. The Prevalence of Intradialytic Hypotension in Patients on Conventional Hemodialysis: A Systematic Review with Meta-Analysis. Am J Nephrol 2019; 49:497-506. [PMID: 31129661 DOI: 10.1159/000500877] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 04/24/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intradialytic hypotension (IDH) is considered to be a frequent complication of hemodialysis (HD) and is associated with symptom burden, increased incidence of access failure, cardiovascular events, and higher mortality. This systematic literature review aims to analyse studies that investigated the prevalence of IDH. A complicating factor herein is that many different definitions of IDH are used in literature. METHODS A systematic literature search from databases, Medline, Cinahl, EMBASE, and the Cochrane library to identify studies reporting on the actual prevalence of IDH was conducted. Studies were categorized by the type of definition used for the prevalence of IDH. A meta-analysis of the prevalence of IDH was performed. RESULTS In a meta-analysis comprising 4 studies including 1,694 patients and 4 studies including 13,189 patients, the prevalence of HD sessions complicated by IDH was 10.1 and 11.6% for the European Best Practice Guideline (EBPG) definition and the Nadir <90 definition, respectively. The proportion of patients with frequent IDH could not reliably be established because of the wide range in cutoff values that were used to identify patients with frequent IDH. There was a large variety in the prevalence of symptoms and interventions. Major risk factors associated with IDH across studies were diabetes, a higher interdialytic weight gain, female gender, and lower body weight. CONCLUSION Our meta-analysis suggests that the prevalence of IDH is lower than 12% for both the EBPG and the Nadir <90 definition which is much lower than stated in most reviews.
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Affiliation(s)
| | - Loes M Verboom
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Karin J R Ipema
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wolter Paans
- Hanze University Groningen, University of Applied Sciences, Groningen, The Netherlands
| | - Wim P Krijnen
- Hanze University Groningen, University of Applied Sciences, Groningen, The Netherlands
| | - Carlo A J M Gaillard
- Division of Internal Medicine and Dermatology, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Casper F M Franssen
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Kuipers J, Oosterhuis JK, Paans W, Krijnen WP, Gaillard CAJM, Westerhuis R, Franssen CFM. Association between quality of life and various aspects of intradialytic hypotension including patient-reported intradialytic symptom score. BMC Nephrol 2019; 20:164. [PMID: 31088398 PMCID: PMC6518736 DOI: 10.1186/s12882-019-1366-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 04/30/2019] [Indexed: 12/15/2022] Open
Abstract
Background There is increasing awareness that, besides patient survival, Quality of Life (QOL) is a relevant outcome factor for patients who have a chronic disease. In haemodialysis (HD) patients, intradialytic hypotension (IDH) is considered one of the most frequent complications, and this is often accompanied by symptoms. Several studies have investigated QOL in dialysis patients, however, research on the association between intradialytic symptoms and QOL is minimal. The goal of this study was to determine whether the occurrence of IDH has an influence on the perception of QOL. Methods During 3 months, haemodynamic data, clinical events, and interventions of 2623 HD-sessions from 82 patients were prospectively collected. The patients filled out a patient-reported intradialytic symptom score (PRISS) after each HD session. IDH was defined according to the EBPG as a decrease in SBP ≥20 mmHg or in MAP ≥10 mmHg associated with a clinical event and need for nursing interventions. Patient’s self-assessment of QOL was evaluated by the 36-Item Short-Form Health Survey. Results There were no significant associations between the mental summary score or the physical summary score and the proportion of dialysis sessions that fulfilled the full EBPG definition. A lower PRISS was significantly associated with the proportion of dialysis sessions that fulfilled the full EBPG definition (R = − 0.35, P = 0.0011), the proportion of dialysis sessions with a clinical event (R = − 0.64, P = 0.001), and the proportion of dialysis sessions with nursing interventions (R = − 0.41, P = 0.0001). The physical component summary and mental component summary were significantly negatively associated with the variable diabetes and positively with PRISS (P = 0.003 and P = 0.005, respectively). UF volume was significantly negatively associated with mental health (P = 0.02) and general health (P = 0.01). Conclusions Our findings suggest that the EBPG definition of IDH does not capture aspects of intradialytic symptomatology that are relevant for the patient’s QOL. In contrast, we found a significant association between QOL and a simple patient-reported intra-dialytic symptom score, implying that how patients experience HD treatment influences their QOL. Electronic supplementary material The online version of this article (10.1186/s12882-019-1366-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Johanna Kuipers
- Dialysis Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands.
| | - Jurjen K Oosterhuis
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wolter Paans
- Hanze University Groningen, University of Applied Sciences, Groningen, The Netherlands
| | - Wim P Krijnen
- Hanze University Groningen, University of Applied Sciences, Groningen, The Netherlands
| | - Carlo A J M Gaillard
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,University of Utrecht Medical Center, University of Utrecht, Utrecht, The Netherlands
| | - Ralf Westerhuis
- Dialysis Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - Casper F M Franssen
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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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: 45] [Impact Index Per Article: 7.5] [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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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: 0.3] [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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Park S, Kim WJ, Cho NJ, Choi CY, Heo NH, Gil HW, Lee EY. Predicting intradialytic hypotension using heart rate variability. Sci Rep 2019; 9:2574. [PMID: 30796327 PMCID: PMC6385196 DOI: 10.1038/s41598-019-39295-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 01/21/2019] [Indexed: 12/12/2022] Open
Abstract
This study aimed to identify whether a new method using heart rate variability (HRV) could predict intradialytic hypotension (IDH) for one month in advance for patients undergoing prevalent hemodialysis. A total 71 patients were enrolled, and baseline clinical characteristics and laboratory results were collected when HRV was measured, then, the frequency of IDH was collected during the observation period. HRV parameters included heart rate, R-R interval, the standard deviation of N-N interval, the square root of the mean squared differences of successive NN intervals, very low frequency, low frequency, high frequency, total power, and low frequency/high frequency ratio. During the one-month observation period, 28 patients experienced 85 cases of IDH (10.0% of a total 852 dialysis sessions). Among the clinical and laboratory parameters, ultrafiltration rate, prior history of diabetes, coronary artery disease, or congestive heart failure, age, intact parathyroid hormone level, and history of antihypertensive drug use were integrated into the multivariate model, referred to as a basic model, which showed significant ability to predict IDH (the area-under-curve [AUC], 0.726; p = 0.002). In HRV parameters, changes between the early and middle phases of hemodialysis (referred to Δ) were identified as significant independent variables. New models were built from the combination of Δ values with the basic model. Among them, a model with the highest AUC value (AUC, 804; p < 0.001) was compared to the basic model and demonstrated improved performance when HRV parameters were used (p = 0.049). Based on our results, it is possible that future IDH might be predicted more accurately using HRV.
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Affiliation(s)
- Samel Park
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Wook-Joon Kim
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Nam-Jun Cho
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Chi-Young Choi
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Nam Hun Heo
- Department of Biostatistics, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Hyo-Wook Gil
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Eun Young Lee
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea.
- Institute of Tissue Regeneration, College of Medicine, Soonchunhyang University, Cheonan, Korea.
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Abstract
BACKGROUND Cardiovascular (CV) disease is the leading cause of death in dialysis patients, and strongly associated with fluid overload and hypertension. It is plausible that low dialysate [Na+] may decrease total body sodium content, thereby reducing fluid overload and hypertension, and ultimately reducing CV morbidity and mortality. OBJECTIVES This review evaluated harms and benefits of using a low (< 138 mM) dialysate [Na+] for maintenance haemodialysis (HD) patients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 7 August 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs), both parallel and cross-over, of low (< 138 mM) versus neutral (138 to 140 mM) or high (> 140 mM) dialysate [Na+] for maintenance HD patients were included. DATA COLLECTION AND ANALYSIS Two investigators independently screened studies for inclusion and extracted data. Statistical analyses were performed using random effects models, and results expressed as risk ratios (RR) for dichotomous outcomes, and mean differences (MD) or standardised MD (SMD) for continuous outcomes, with 95% confidence intervals (CI). Confidence in the evidence was assessed using GRADE. MAIN RESULTS We included 12 studies randomising 310 patients, with data available for 266 patients after dropout. All but one study evaluated a fixed concentration of low dialysate [Na+], and one profiled dialysate [Na+]. Three studies were parallel group, and the remaining nine cross-over. Of the latter, only two used a washout between intervention and control periods. Most studies were short-term with a median (interquartile range) follow-up of 3 (3, 8.5) weeks. Two were of a single HD session, and two of a single week's HD. Half of the studies were conducted prior to 2000, and five reported use of obsolete HD practices. Risks of bias in the included studies were often high or unclear, lowering confidence in the results.Compared to neutral or high dialysate [Na+], low dialysate [Na+] had the following effects on "efficacy" endpoints: reduced interdialytic weight gain (10 studies: MD -0.35 kg, 95% CI -0.18 to -0.51; high certainty evidence); probably reduced predialysis mean arterial blood pressure (BP) (4 studies: MD -3.58 mmHg, 95% CI -5.46 to -1.69; moderate certainty evidence); probably reduced postdialysis mean arterial BP (MAP) (4 studies: MD -3.26 mmHg, 95% CI -1.70 to -4.82; moderate certainty evidence); probably reduced predialysis serum [Na+] (7 studies: MD -1.69 mM, 95% CI -2.36 to -1.02; moderate certainty evidence); may have reduced antihypertensive medication (2 studies: SMD -0.67 SD, 95% CI -1.07 to -0.28; low certainty evidence). Compared to neutral or high dialysate [Na+], low dialysate [Na+] had the following effects on "safety" endpoints: probably increased intradialytic hypotension events (9 studies: RR 1.56, 95% 1.17 to 2.07; moderate certainty evidence); probably increased intradialytic cramps (6 studies: RR 1.77, 95% 1.15 to 2.73; moderate certainty evidence).Compared to neutral or high dialysate [Na+], low dialysate [Na+] may make little or no difference to: intradialytic BP (2 studies: MD for systolic BP -3.99 mmHg, 95% CI -17.96 to 9.99; diastolic BP 1.33 mmHg, 95% CI -6.29 to 8.95; low certainty evidence); interdialytic BP (2 studies:, MD for systolic BP 0.17 mmHg, 95% CI -5.42 to 5.08; diastolic BP -2.00 mmHg, 95% CI -4.84 to 0.84; low certainty evidence); dietary salt intake (2 studies: MD -0.21g/d, 95% CI -0.48 to 0.06; low certainty evidence).Due to very low quality of evidence, it is uncertain whether low dialysate [Na+] changed extracellular fluid status, venous tone, arterial vascular resistance, left ventricular mass or volumes, thirst or fatigue. Studies did not examine cardiovascular or all-cause mortality, cardiovascular events, or hospitalisation. AUTHORS' CONCLUSIONS It is likely that low dialysate [Na+] reduces intradialytic weight gain and BP, which are effects directionally associated with improved outcomes. However, the intervention probably also increases intradialytic hypotension and reduces serum [Na+], effects that are associated with increased mortality risk. The effect of the intervention on overall patient health and well-being is unknown. Further evidence is needed in the form of longer-term studies in contemporary settings, evaluating end-organ effects in small-scale mechanistic studies using optimal methods, and clinical outcomes in large-scale multicentre RCTs.
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Affiliation(s)
- Joanna L Dunlop
- Counties Manukau HealthDepartment of MedicineOrakau RdAucklandNew Zealand
| | - Alain C Vandal
- Auckland University of TechnologyDepartment of BiostatisticsPrivate Bag 92006AucklandAucklandNew Zealand1142
- Counties Manukau HealthKo AwateaAucklandNew Zealand
| | - Mark R Marshall
- Counties Manukau HealthDepartment of MedicineOrakau RdAucklandNew Zealand
- University of AucklandSchool of Medicine, Faculty of Medical and Health SciencesAucklandNew Zealand
- Baxter Healthcare (Asia) Pty LtdMedical AffairsSingaporeSingapore
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Korucu B, Helvaci O, Ozbas B, Yeter H, Yuce D, Elbeg S, Derici U. Low Copeptin Levels in Patients With Intradialytic Hypotension. Ther Apher Dial 2018; 23:460-466. [PMID: 30549206 DOI: 10.1111/1744-9987.12784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/06/2018] [Accepted: 12/11/2018] [Indexed: 12/25/2022]
Abstract
Intradialytic hypotension (IDH) is related to high morbidity and mortality. There is evidence that arginine-vasopressin (AVP) responses could play a role. Copeptin is a reliable biomarker of AVP. In this study, copeptin, aldosterone, epinephrine, and norepinephrine levels in patients with IDH were evaluated throughout a hemodialysis (HD) session and compared with the control group. The study includes 15 patients who were normotensive during HD and 15 patients with IDH with a minimum HD vintage of 1 year. Blood samples were collected before the initiation of an HD session (T0 ), in the mid-session for control group, 30 min after mean arterial pressure drop for IDH patients (T1 ), and at the end of the session (T2 ). Groups had similar demographic features and health parameters, interdialytic weight gains, and ultrafiltration amounts. The IDH group had a mean arterial pressure decline of 39.9 (±6.4) mm Hg. Copeptin levels of the control group increased an average of 79.9 (±97.5) pmol/L at T1 and an additional 24.8 (±33.9) pmol/L at T2 . In the IDH group, copeptin level increases at T1 and T2 were 3.2 (±5.5) pmol/L and 34 (±44.6) pmol/L, respectively. Copeptin levels of the IDH group were significantly lower at T1 (P < 0.001) and at the T0 -T2 interval than control group (P = 0.05). In the control group, aldosterone levels distinctly decreased, and in the IDH group, aldosterone levels were elevated (P < 0.001). Small changes were detected in epinephrine and norepinephrine levels for both groups but did not reach significance (P = 0.6 and P = 0.3, respectively). Lower copeptin level alterations suggest inadequate AVP responses in patients with IDH.
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Affiliation(s)
- Berfu Korucu
- Department of Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ozant Helvaci
- Department of Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Burak Ozbas
- Department of Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Hasan Yeter
- Department of Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Deniz Yuce
- Department of Preventive Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Sehri Elbeg
- Department of Biochemistry, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ulver Derici
- Department of Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey
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Chou JA, Streja E, Nguyen DV, Rhee CM, Obi Y, Inrig JK, Amin A, Kovesdy CP, Sim JJ, Kalantar-Zadeh K. Intradialytic hypotension, blood pressure changes and mortality risk in incident hemodialysis patients. Nephrol Dial Transplant 2018; 33:149-159. [PMID: 28444336 DOI: 10.1093/ndt/gfx037] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 02/06/2017] [Indexed: 12/15/2022] Open
Abstract
Background Intradialytic hypotension (IDH) occurs frequently in maintenance hemodialysis (HD) patients and may be associated with higher mortality. We hypothesize that nadir intradialytic systolic blood pressure (niSBP) is inversely related to death risk while iSBP change (Δ) and IDH frequency are incrementally associated with all-cause mortality. Methods In a US-based cohort of 112 013 incident HD patients over a 5-year period (2007-11), using niSBP, ΔiSBP (pre-HD SBP minus niSBP) and IDH frequency (proportion of HD treatments with niSBP <90 mmHg) within the first 91 days of HD, we examined mortality-predictability at 1, 2 and 5 years using Cox models and restricted cubic splines adjusted for case-mix, comorbidities and laboratory covariates. Results We observed that niSBP of <90 and ≥140 mmHg had a 5-year mortality hazard ratio (HR) (95% confidence interval) of 1.57 (1.47-1.67) and 1.25 (1.18-1.33), respectively, compared with niSBP 110 to <120 mmHg. ΔiSBP of <15 and ≥50 compared with 21-30 mmHg had mortality HR of 1.31 (1.26-1.37) and 1.32 (1.24-1.39), respectively. Among patients with >40% IDH frequency, we observed a mortality HR of 1.49 (1.42-1.57) compared with 0% IDH frequency in fully adjusted models. These associations were robust at 1 and 2 years of follow-up. Conclusion In conclusion, we observed a U-shaped association between niSBP and ΔiSBP and mortality and a direct linear relationship between IDH frequency and mortality. Our findings lend some prognostic insight of HD blood pressure and hemodynamics, and have the potential to guide blood pressure management strategies among the HD population.
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Affiliation(s)
- Jason A Chou
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Danh V Nguyen
- Department of Medicine, University of California, Irvine, School of Medicine, Orange, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Jula K Inrig
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA.,Quintiles Therapeutic Science and Strategy Unit, San Diego, California
| | - Alpesh Amin
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
| | - John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Medical Center, Los Angeles, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA.,Fielding School of Public Health at UCLA, Los Angeles, CA, USA.,Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA, USA
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Twardowski ZJ, Misra M. A need for a paradigm shift in focus: From Kt/V urea to appropriate removal of sodium (the ignored uremic toxin). Hemodial Int 2018; 22:S29-S64. [PMID: 30457224 DOI: 10.1111/hdi.12701] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Hemodialysis for chronic renal failure was introduced and developed in Seattle, WA, in the 1960s. Using Kiil dialyzers, weekly dialysis time and frequency were established to be about 30 hours on 3 time weekly dialysis. This dialysis time and frequency was associated with 10% yearly mortality in the United States in 1970s. Later in 1970s, newer and more efficient dialyzers were developed and it was felt that dialysis time could be shortened. An additional incentive to shorten dialysis was felt to be lower cost and higher convenience. Additional support for shortening dialysis time was provided by a randomized prospective trial performed by National Cooperative Dialysis Study (NCDS). This study committed a Type II statistical error rejecting the time of dialysis as an important factor in determining the quality of dialysis. This study also provided the basis for the establishment of the Kt/Vurea index as a measure of dialysis adequacy. This index having been established in a sacrosanct randomized controlled trial (RCT), was readily accepted by the HD community, and led to shorter dialysis, and higher mortality in the United States. Kt/Vurea is a poor measure of dialysis quality because it combines three unrelated variables into a single formula. These variables influence the clinical status of the patient independent of each other. It is impossible to compensate short dialysis duration (t) with the increased clearance of urea (K), because the tolerance of ultrafiltration depends on the plasma-refilling rate, which has nothing in common with urea clearance. Later, another RCT (the HEMO study) committed a Type III statistical error by asking the wrong research question, thus not yielding any valuable results. Fortunately, it did not lead to deterioration of dialysis outcomes in the United States. The third RCT in this field ("in-center hemodialysis 6 times per week versus 3 times per week") did not bring forth any valuable results, but at least confirmed what was already known. The fourth such trial ("The effects of frequent nocturnal home hemodialysis") too did not show any positive results primarily due to significant subject recruitment issues leading to inappropriate selection of patients. Comparison of the value of peritoneal dialysis and HD in RCTs could not be completed because of recruitment problems. Randomized controlled trials have therefore failed to yield any meaningful information in the area of dose and or frequency of hemodialysis.
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Affiliation(s)
| | - Madhukar Misra
- Department of Medicine, University of Missouri, Columbia, Missouri, USA
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Impact of intradialytic blood pressure changes on cardiovascular outcomes is independent of the volume status of maintenance hemodialysis patients. ACTA ACUST UNITED AC 2018; 12:779-788. [PMID: 30031744 DOI: 10.1016/j.jash.2018.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 05/02/2018] [Accepted: 06/19/2018] [Indexed: 12/31/2022]
Abstract
Intradialytic systolic blood pressure (SBP) changes are related to the volume status; however, whether SBP change impacts on adverse outcomes depends on the volume status remains uncertain. We retrospectively investigated the relationship among intradialytic changes in SBP, cardiovascular outcomes, and volume status in maintenance hemodialysis patients. We determined SBP changes (ΔSBP) as postdialysis SBP minus predialysis SBP and volume status as the ratio of extracellular water to total body water (ECW/TBW) using bioelectrical impedance analysis. There were 82 (60.3%) with ΔSBP -20 to 10 mm Hg, 21 (15.4%) with ΔSBP ≤ -20 mm Hg, and 33 (24.3%) with ΔSBP ≥ 10 mm Hg, and they were followed up for a median of 34 months. Cardiovascular events more frequently occurred in the patients with ΔSBP ≤ -20 mm Hg and ≥ 10 mm Hg (hazard ratio: 2.3 and 3.0; P = .062 and .006); these associations persisted even after adjusting for postdialysis ECW/TBW (P = .056 and .028). Moreover, ΔSBP ≥ 10 mm Hg was associated with increased cardiovascular mortalities independent of postdialysis ECW/TBW (P = .043). There was an independent association of volume status between considerable SBP decrease or increase during hemodialysis and adverse cardiovascular outcomes. Besides appropriate volume control, other factors related to BP changes during hemodialysis must be investigated.
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Naderi N, Kleine CE, Park C, Hsiung JT, Soohoo M, Tantisattamo E, Streja E, Kalantar-Zadeh K, Moradi H. Obesity Paradox in Advanced Kidney Disease: From Bedside to the Bench. Prog Cardiovasc Dis 2018; 61:168-181. [PMID: 29981348 DOI: 10.1016/j.pcad.2018.07.001] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 07/02/2018] [Indexed: 02/06/2023]
Abstract
While obesity is associated with a variety of complications including diabetes, hypertension, cardiovascular disease and premature death, observational studies have also found that obesity and increasing body mass index (BMI) can be linked with improved survival in certain patient populations, including those with conditions marked by protein-energy wasting and dysmetabolism that ultimately lead to cachexia. The latter observations have been reported in various clinical settings including end-stage renal disease (ESRD) and have been described as the "obesity paradox" or "reverse epidemiology", engendering controversy. While some have attributed the obesity paradox to residual confounding in an effort to "debunk" these observations, recent experimental discoveries provide biologically plausible mechanisms in which higher BMI can be linked to longevity in certain groups of patients. In addition, sophisticated epidemiologic methods that extensively adjusted for confounding have found that the obesity paradox remains robust in ESRD. Furthermore, novel hypotheses suggest that weight loss and cachexia can be linked to adverse outcomes including cardiomyopathy, arrhythmias, sudden death and poor outcomes. Therefore, the survival benefit observed in obese ESRD patients can at least partly be derived from mechanisms that protect against inefficient energy utilization, cachexia and protein-energy wasting. Given that in ESRD patients, treatment of traditional risk factors has failed to alter outcomes, detailed translational studies of the obesity paradox may help identify innovative pathways that can be targeted to improve survival. We have reviewed recent clinical evidence detailing the association of BMI with outcomes in patients with chronic kidney disease, including ESRD, and discuss potential mechanisms underlying the obesity paradox with potential for clinical applicability.
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Affiliation(s)
- Neda Naderi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Department of Internal Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Carola-Ellen Kleine
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA
| | - Jui-Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA; Dept. of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA; Dept. of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA.
| | - Hamid Moradi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA.
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