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Nakazawa R, Nagami S, Nozaki H, Yataka M, Inada Y, Akiyama K, Uchino T, Azuma N. Renal replacement strategies: dual benefits of hydrogen gas inhalation and hydrogen-enriched dialysate. Med Gas Res 2025; 15:444-445. [PMID: 40251026 PMCID: PMC12054674 DOI: 10.4103/mgr.medgasres-d-24-00130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2024] [Revised: 12/27/2024] [Accepted: 01/17/2025] [Indexed: 04/20/2025] Open
Affiliation(s)
- Ryoichi Nakazawa
- Department of Nephrology, Tokatsu-Clinic Hospital, Matsudo, Japan
| | - Shintaro Nagami
- Department of Clinical Engineering, Tokatsu-Clinic Hospital, Matsudo, Japan
| | - Hiroshi Nozaki
- Department of Clinical Engineering, Tokatsu-Clinic Hospital, Matsudo, Japan
| | - Minako Yataka
- Department of Clinical Engineering, Tokatsu-Clinic Hospital, Matsudo, Japan
| | - Yoji Inada
- Department of Clinical Engineering, Tokatsu-Clinic Hospital, Matsudo, Japan
| | - Kazuhiro Akiyama
- Department of Surgery, Tokatsu-Clinic Hospital, Matsudo, Japan (Akiyama K, Uchino T, Azuma N)
| | - Takashi Uchino
- Department of Surgery, Tokatsu-Clinic Hospital, Matsudo, Japan (Akiyama K, Uchino T, Azuma N)
| | - Nakanobu Azuma
- Department of Surgery, Tokatsu-Clinic Hospital, Matsudo, Japan (Akiyama K, Uchino T, Azuma N)
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2
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Yokomine T, Kajiya T, Takei T, Kitazono K, Ninomiya T, Inoue T, Takaoka J, Atsuchi Y, Atsuchi N, Ohishi M. Impact of Calcified Nodules on Clinical Outcomes in Hemodialysis Patients Undergoing Percutaneous Coronary Intervention. Am J Cardiol 2025; 245:35-37. [PMID: 40064222 DOI: 10.1016/j.amjcard.2025.03.007] [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] [Received: 01/30/2025] [Revised: 03/04/2025] [Accepted: 03/05/2025] [Indexed: 03/26/2025]
Abstract
Calcified nodules (CNs) are associated with poor prognosis after percutaneous coronary intervention (PCI) and have been reported to occur more frequently in hemodialysis patients. However, their prognosis in hemodialysis patients undergoing PCI has not been fully elucidated. We aimed to investigate the prognosis of hemodialysis patients who underwent PCI for CNs using intravascular ultrasound (IVUS) and/or optical coherence tomography (OCT)/optical frequency domain imaging (OFDI). About 141 hemodialysis patients who underwent PCI between January 2020 and December 2021 were analyzed retrospectively in a single center. CNs are defined as heavily calcified plaques that protruding into lumen in a convex shape. MACE (a composite of cardiovascular death, target lesion related myocardial infarction, and target lesion revascularization) between CNs and Non-CNs at 1 year were compared. In the entire study population, the mean age was 69.3 ± 10.7 years, and 94 (77.0%) were male. At 1 year, the incidence of MACE following PCI was significantly higher in the CNs group (39.2% vs 9.9%, log-rank p <0.001), particularly for cardiovascular death (17.7% vs 4.2%, log-rank p = 0.009). After multivariate analysis adjusting for demographic characteristics, CNs remained independently associated with increased risk of MACE (adjusted hazard ratio: 4.93, 95% confidence interval 2.07 to 11.76; p <0.001). CNs were associated with a higher incidence of MACE and a higher cardiovascular death rate in hemodialysis patients who underwent PCI.
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Affiliation(s)
- Tatsuo Yokomine
- Department of Cardiology, Tenyoukai Central Hospital, Kagoshima, Japan; Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Takashi Kajiya
- Department of Cardiology, Tenyoukai Central Hospital, Kagoshima, Japan.
| | - Tatsuro Takei
- Department of Cardiology, Tenyoukai Central Hospital, Kagoshima, Japan
| | - Kazunari Kitazono
- Department of Cardiology, Tenyoukai Central Hospital, Kagoshima, Japan
| | - Toshiko Ninomiya
- Department of Cardiology, Tenyoukai Central Hospital, Kagoshima, Japan
| | - Takafumi Inoue
- Department of Cardiology, Tenyoukai Central Hospital, Kagoshima, Japan
| | - Junichiro Takaoka
- Department of Cardiology, Tenyoukai Central Hospital, Kagoshima, Japan
| | - Yoshihiko Atsuchi
- Department of Cardiology, Tenyoukai Central Hospital, Kagoshima, Japan
| | - Nobuhiko Atsuchi
- Department of Cardiology, Tenyoukai Central Hospital, Kagoshima, Japan
| | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
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3
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Sakhare Y, Almeida A, Phalgune D, Erande A, Mehendale SM. The Frequency, Causes and Patterns of Asymptomatic Cardiac Arrhythmias in Patients on Maintenance Hemodialysis. Indian J Nephrol 2025; 35:397-401. [PMID: 40352881 PMCID: PMC12065607 DOI: 10.25259/ijn_412_23] [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: 01/17/2024] [Accepted: 05/31/2024] [Indexed: 05/14/2025] Open
Abstract
Background The knowledge of the incidence of non-severe and clinically significant arrhythmias is limited in patients with chronic kidney disease (CKD). The present study was conducted to determine the incidence, pattern and identify the factors predisposing to cardiac arrhythmias in patients on maintenance hemodialysis. Materials and Methods Forty-five patients were included in this prospective observational study conducted between June 2020 and November 2021. Patients ≥ 18 years of age on maintenance hemodialysis (three times/week for at least three months), with no intercurrent illness, uremic symptoms, and not hospitalized in the previous 3 months were included. Demographic and clinical characteristics of the patients were noted. Arrhythmias were recorded by attaching the Holter machine to all study patients undergoing hemodialysis. We estimated the incidence, identified the pattern of cardiac arrhythmias, and explored the factors predisposing to cardiac arrhythmias. Results Premature atrial complexes (17.8%), premature ventricular complexes (31.1%), ventricular bigeminy (8.9%), trigeminy (8.9%), and ventricular couplets (22.2%) were observed. The patients with hyperparathyroidism, hyper/hypomagnesemia, and poor blood pressure control had significantly higher percentages of total and ventricular arrhythmias. The patients with hypomagnesemia, reduced left ventricular ejection fraction (<50%), poor blood pressure control, and receiving statins had significantly higher percentages of atrial arrhythmias. There was no statistically significant association between age, gender, diabetes mellitus, ischaemic heart disease, interdialytic weight gain, dialysis vintage, low hemoglobin, serum calcium levels, serum potassium levels, presence of left ventricular hypertrophy, pulmonary hypertension, and diastolic dysfunction with arrhythmias. Conclusion A high incidence of cardiac arrhythmias was noted among patients on hemodialysis.
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Affiliation(s)
- Yamita Sakhare
- Department of Nephrology, P D Hinduja National Hospital and Medical Research Centre, Mahim, Mumbai, India
| | - Alan Almeida
- Department of Nephrology, P D Hinduja National Hospital and Medical Research Centre, Mahim, Mumbai, India
| | - Deepak Phalgune
- Department of Research, P D Hinduja National Hospital and Medical Research Centre, Mahim, Mumbai, India
| | - Aditi Erande
- Department of Research, P D Hinduja National Hospital and Medical Research Centre, Mahim, Mumbai, India
| | - Sanjay Madhav Mehendale
- Department of Research, P D Hinduja National Hospital and Medical Research Centre, Mahim, Mumbai, India
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4
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McIntyre CW, Jain A. Dialysis and cognitive impairment. Nat Rev Nephrol 2025:10.1038/s41581-025-00960-3. [PMID: 40275017 DOI: 10.1038/s41581-025-00960-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2025] [Indexed: 04/26/2025]
Abstract
People with chronic kidney disease who require maintenance dialysis characteristically experience accelerated and aggravated cognitive decline compared with those with advanced kidney disease who are not receiving this form of kidney replacement therapy. This effect is inadequately appreciated, but of crucial importance to patients, their carers and the health-care systems that support them. Although many of the comorbid conditions prevalent in this patient population have the potential to affect brain structure and function, an evolving body of evidence indicates that the dialysis therapy itself has a central role in the pathophysiology of progressive cognitive impairment. Both haemodialysis and peritoneal dialysis are associated with structural and functional changes in the brain that can lead to characteristic short-term symptoms, such as headache, confusion, delirium and brain fog, as well as long-term reductions in cognitive functional ability. Here, we explore the mechanisms, both established and putative, underlying these effects and consider approaches to addressing this issue with both single and complex therapeutic interventions.
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Affiliation(s)
- Chris W McIntyre
- Lilibeth Caberto Kidney Clinical Research Unit, Lawson Health Research Institute, London, Ontario, Canada.
- Departments of Medicine, Medical Biophysics and Paediatrics, Western University, London, Ontario, Canada.
| | - Arsh Jain
- Lilibeth Caberto Kidney Clinical Research Unit, Lawson Health Research Institute, London, Ontario, Canada
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Wu HC, Wang WJ. Utility of Central Venous Oxygen Saturation Gradient in Predicting Mortality in Dialysis with Catheter Access. Med Sci Monit 2025; 31:e947298. [PMID: 40119496 PMCID: PMC11938988 DOI: 10.12659/msm.947298] [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] [Subscribe] [Scholar Register] [Received: 11/16/2024] [Accepted: 01/24/2025] [Indexed: 03/24/2025] Open
Abstract
BACKGROUND Central venous oxygen saturation (ScvO2), a biomarker that is well-correlated with arterial oxygen saturation, can predict mortality. Few studies have focused on blood volume, ScvO2, and mortality in patients on maintenance dialysis. This retrospective study used hospital record data of 144 dialysis patients with central venous catheter access (CVC) and aimed to evaluate the ScvO2 gradient, blood volume, and patient mortality. We examined the associations among absolute blood volume (ABV), mean ScvO2, intradialytic slope of ScvO2, and mortality in patients on dialysis. MATERIAL AND METHODS Adult patients receiving dialysis via CVC from 2022 to 2024 were enrolled. ScvO2, ABV, and protocol-based ultrafiltration were monitored using Crit-Line IV (Fresenius Medical Care, Bad Homburg, Germany). Participants were assessed and followed until death or administrative censor. Multiple fractional polynomial (MFP) regression was used to determine best-fitting polynomial function between predictors and mortality. We also constructed proportional hazard model to compare trends of ScvO2 for mortality. RESULTS In a total of 144 eligible patients, the incidence of mortality was 14.5 per 1000 patient-months. The correlation between mean ScvO2 and mortality was weak (r=-0.05), whereas the association between ABV change and mean ScvO2 were a reverse U curve. The intradialytic slope of ScvO2 was independently associated with mortality (adjusted odds ratio [95% CI]=0.421 [0.226-0.783], P<0.05). Those with descending slope of ScvO2 had higher risk of mortality than those with an ascending slope (HR [95% CI]=3.98 [1.22-13.03], P<0.05). CONCLUSIONS A negative trend of intradialytic ScvO2 was associated with mortality.
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Affiliation(s)
- Hung-Chieh Wu
- Division of Nephrology, Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
- Department of Biotechnology, Ming Chuan University, Taipei, Taiwan
| | - Wei-Jie Wang
- Department of Internal Medicine, Lo-Sheng Sanatorium and Hospital, Taoyuan, Taiwan
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Ito T, Shinzato T. Liver Blood Stagnation: An Overlooked but Significant Factor in Intradialytic Hypotension. Kidney Blood Press Res 2025; 50:259-266. [PMID: 40058360 DOI: 10.1159/000545113] [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: 10/05/2024] [Accepted: 03/04/2025] [Indexed: 04/17/2025] Open
Abstract
BACKGROUND Intradialytic hypotension (IDH) occurs suddenly and without warning, although it is generally reversible. While ultrafiltration rate, cardiac function, and vascular resistance have been widely studied, more attention should be given to venous blood return to the heart in relation to blood stagnation. Both existing literature and clinical observations suggest that as a hemodialysis session progresses, the vascular bed of the liver expands, reducing venous return to the heart. This decrease in cardiac output may further increase hepatic blood volume, potentially playing a central role in the development of IDH. SUMMARY This review explores the role of reduced venous return to the heart, caused by liver blood stagnation, as a key contributor to IDH. KEY MESSAGES We tentatively name this pathophysiological mechanism "liver circulation jam." The clinical significance of this concept requires validation through future research.
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Affiliation(s)
- Takahito Ito
- Division of Nephrology, Minatonomori Hospital, Kobe, Japan
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Shringi S, Shah A. The cardiovascular unphysiology of thrice weekly hemodialysis. Curr Opin Nephrol Hypertens 2025; 34:69-76. [PMID: 39498607 PMCID: PMC11606746 DOI: 10.1097/mnh.0000000000001037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2024]
Abstract
PURPOSE OF REVIEW This review examines the unphysiological nature of conventional intermittent hemodialysis (IHD) and explores alternative dialysis modalities that more closely mimic natural kidney function. As cardiovascular complications remain a leading cause of morbidity and mortality in dialysis patients, understanding and addressing the limitations of IHD is crucial for improving outcomes. RECENT FINDINGS IHD's intermittent nature leads to significant fluctuations in metabolites, electrolytes, and fluid status, contributing to hemodynamic instability and increased cardiovascular risk. More frequent dialysis modalities, such as short daily hemodialysis and nocturnal hemodialysis have numerous benefits including reduced left ventricular hypertrophy, improved blood pressure control, and potentially decreasing mortality. Peritoneal dialysis offers a more continuous approach to treatment, which may provide cardiovascular benefits through gentler fluid removal and residual kidney function preservation. SUMMARY Conventional thrice weekly intermittent hemodialysis offers a fundamentally unphysiologic equilibrium of uremic solutes. Alternate approaches have demonstrated cardiovascular benefits.
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Affiliation(s)
- Sandipan Shringi
- Warren Alpert Medical School of Brown University, Providence, RI
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Providence, Rhode Island
| | - Ankur Shah
- Warren Alpert Medical School of Brown University, Providence, RI
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Providence, Rhode Island
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8
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Rootjes PA, Grooteman MP, Budding AE, Bontkes HJ, Wijngaarden G, Nubé MJ, de Roij van Zuijdewijn CL. Randomized Trial Demonstrating No Translocation of Intact Intestinal Bacteria During Hemodialysis or Hemodiafiltration. Kidney Int Rep 2025; 10:109-119. [PMID: 39810793 PMCID: PMC11725968 DOI: 10.1016/j.ekir.2024.09.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 09/27/2024] [Accepted: 09/30/2024] [Indexed: 01/16/2025] Open
Abstract
Introduction The low incidence of intradialytic hypotension (IDH) in high-volume (HV) hemodiafiltration (HDF) may help in maintaining gut perfusion during treatment. Preservation of gut endothelial integrity would limit or prevent bacterial translocation and subsequent systemic inflammation, which may contribute to the low mortality rate in HV-HDF. Methods Forty patients were cross-over randomized to standard (hemodialysis [HD]) (S-HD), cool HD (C-HD), and HDF (low-volume [LV] and HV, convection volume (CV) of 15 L and ≥ 23 L per session, respectively), each for 2 weeks. Quantitative assessment of microbial DNA (mDNA) in blood was performed before and after dialysis by 16S to 23S interspace profiling after DNA isolation. The intradialytic acute phase response (APR) was evaluated by high-sensitivity C-reactive protein (hs-CRP), interleukin-6 receptor (IL-6R), soluble CD14 (sCD14), and vascular-cell-adhesion molecule-1 (VCAM-1). Differences between modalities were primary objectives. Results mDNA was absent from all samples. IL-6R, sCD14, and VCAM-1 increased equally in all modalities (median increase: 12.5%, 14.0%, 14.8%, respectively; P < 0.05). hs-CRP increased only in C-HD and HV-HDF (median increase: 12.6%, P < 0.05). After correction for hemoconcentration, most APR markers decreased (median: sCD14, -11.3% and VCAM-1, -14.4% in all modalities; IL-6R, -13.4% in C-HD, LV-HDF, and HV-HDF; P < 0.05). hs-CRP only decreased in C-HD (-13.5%, P = 0.004). Conclusion From this study, we conclude as follows: (i) circulating mDNA could not be demonstrated; (ii) in the crude analysis, a similar APR was noted in all modalities, individual markers remained stable or declined after correction for hemoconcentration; and (iii) because neither bacterial translocation nor an APR was observed in either modality, it is highly unlikely that the superior survival of HV-HDF is explained by a superior preservation of gut integrity.
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Affiliation(s)
- Paul A. Rootjes
- Amsterdam UMC, location AMC, Nephrology, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences (ACS), Diabetes and Metabolism, Amsterdam, the Netherlands
- Department of Internal Medicine, Gelre Hospitals, location Apeldoorn, Apeldoorn, the Netherlands
| | - Muriel P.C. Grooteman
- Amsterdam UMC, location AMC, Nephrology, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences (ACS), Diabetes and Metabolism, Amsterdam, the Netherlands
| | | | - Hetty J. Bontkes
- Department of Clinical Chemistry, Medical Immunology Laboratory and Amsterdam Infection and Immunity, Amsterdam UMC, Amsterdam, the Netherlands
| | - Gertrude Wijngaarden
- Amsterdam UMC, location AMC, Nephrology, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences (ACS), Diabetes and Metabolism, Amsterdam, the Netherlands
| | - Menso J. Nubé
- Amsterdam UMC, location AMC, Nephrology, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences (ACS), Diabetes and Metabolism, Amsterdam, the Netherlands
| | - Camiel L.M. de Roij van Zuijdewijn
- Amsterdam UMC, location AMC, Nephrology, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences (ACS), Diabetes and Metabolism, Amsterdam, the Netherlands
- Department of Internal Medicine, Spaarne Gasthuis, Haarlem, the Netherlands
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9
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Josse M, Patrier L, Cristol JP, Isnard M, Grandperrin A, Turc-Baron C, Nottin S, Mandigout S, Maufrais C, Obert P. Effect of intradialytic exercise training on hemodialysis-induced myocardial stunning: a pilot-controlled trial. Clin Kidney J 2025; 18:sfae352. [PMID: 40008351 PMCID: PMC11852286 DOI: 10.1093/ckj/sfae352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Indexed: 02/27/2025] Open
Abstract
Background Hemodialysis (HD) can lead to left ventricular (LV) transient regional wall motion abnormalities (RWMAs), due to segmental hypoperfusion, better known as myocardial stunning. Repeated episodes of HD-induced ischemia contribute directly to the development of heart failure and increased mortality in patients receiving HD. Intradialytic exercise (IDE) training is capable of exerting favorable effects on the cardiovascular system. However, its impact on HD-induced myocardial stunning remains currently unknown. Methods In this prospective controlled study, 31 patients participating in an intradialytic aerobic and resistance training program (3/week for 16 weeks) were compared with 30 patients receiving usual care. Two-dimensional echocardiography was performed at baseline and follow-up both just before HD onset (T0) and at peak stress of HD (Tpeak). LV longitudinal strain from an 18-segment model were used to assess the presence of RWMAs. Results Training resulted in a significant reduction of RWMAs at Tpeak between groups [-2.22 segments; 95% confidence interval (CI) -0.49/-3.96; P = .01]. Compared with usual care, trained patients demonstrated also a greater reduction in the decline of global longitudinal strain during HD (-1.45%; 95% CI -0.24/-2.66; P = .01). There were significant reductions in LV mass (-23.3 g; 95% CI -8.7/-37.9; P = .002) and improvements in LV ejection fraction (4%; 95% CI 1.5/6.6; P = .002) between groups favoring IDE. Correlations were found between change in RWMAs with change in LV mass and ejection fraction over the study period. Conclusion IDE training is cardioprotective, improving LV remodeling and reducing HD-induced myocardial stunning.
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Affiliation(s)
- Matthieu Josse
- UPR4278 Laboratory of Experimental Cardiovascular Physiology, Avignon University, Avignon, France
| | - Laure Patrier
- Fondation Charles Mion – AIDER Santé, France
- CHU Nîmes, France
| | - Jean-Paul Cristol
- Fondation Charles Mion – AIDER Santé, France
- CHRU, Montpellier, France
- UMR9214 PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | | | - Antoine Grandperrin
- UPR4278 Laboratory of Experimental Cardiovascular Physiology, Avignon University, Avignon, France
| | - Cécile Turc-Baron
- Fondation Charles Mion – AIDER Santé, France
- CHRU, Montpellier, France
| | - Stéphane Nottin
- UPR4278 Laboratory of Experimental Cardiovascular Physiology, Avignon University, Avignon, France
| | | | - Claire Maufrais
- UPR4278 Laboratory of Experimental Cardiovascular Physiology, Avignon University, Avignon, France
| | - Philippe Obert
- UPR4278 Laboratory of Experimental Cardiovascular Physiology, Avignon University, Avignon, France
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Randhay A, Eldehni MT, Selby NM. Feedback control in hemodialysis. Semin Dial 2025; 38:62-70. [PMID: 37994191 PMCID: PMC11867153 DOI: 10.1111/sdi.13185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 11/24/2023]
Abstract
A number of systems of feedback control during dialysis have been developed, which have the shared characteristic of prospectively measuring physiological parameters and then automatically altering dialysis parameters in real time according to a pre-specified dialysis prescription. These include feedback systems aimed at reducing intradialytic hypotension based on relative blood volume monitoring linked to adjustments in ultrafiltration and dialysate conductivity, and blood temperature monitoring linked to alterations in dialysate temperature. Feedback systems also exist that manipulate sodium balance during dialysis by assessing and adjusting dialysate conductivity. In this review article, we discuss the rationale for automated feedback systems during dialysis, describe how the different feedback systems work, and provide a review of the current evidence on their clinical effectiveness.
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Affiliation(s)
- Ashveer Randhay
- Centre for Kidney Research and Innovation, School of MedicineUniversity of NottinghamNottinghamUK
- Department of Renal MedicineRoyal Derby HospitalDerbyUK
| | - Mohamed Tarek Eldehni
- Centre for Kidney Research and Innovation, School of MedicineUniversity of NottinghamNottinghamUK
- Department of Renal MedicineRoyal Derby HospitalDerbyUK
| | - Nicholas M. Selby
- Centre for Kidney Research and Innovation, School of MedicineUniversity of NottinghamNottinghamUK
- Department of Renal MedicineRoyal Derby HospitalDerbyUK
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11
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Manole OM, Haba MȘC, Matei IT, Onofrei V. Rare Clinical Manifestation of Vasculitis. Diagnostics (Basel) 2024; 14:2623. [PMID: 39682532 DOI: 10.3390/diagnostics14232623] [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: 10/17/2024] [Revised: 11/15/2024] [Accepted: 11/19/2024] [Indexed: 12/18/2024] Open
Abstract
BACKGROUND Antineutrophil cytoplasm antibody (ANCA)-associated vasculitis usually affects small blood vessels and is characterized by the presence of circulating autoantibodies (c-ANCA or p-ANCA). The risk of cardiovascular events is threefold higher compared to general population, and cardiac manifestations include myocarditis, pericarditis, valvulitis, aortitis, or coronary arteritis. Coronary involvement is very rare, but it is a potentially life-threatening manifestation. METHODS We present an atypical cardiac scenario of p-ANCA vasculitis. RESULTS A 68-year-old woman with known p-ANCA vasculitis and stage 5 chronic kidney disease (CKD) on hemodialysis presented with dizziness accompanied by low blood pressure and chest pain. Electrocardiogram on arrival showed slightly ST-T changes, with negative cardiac biomarkers and no abnormalities in cardiac regional wall motion. Five hours after presentation, the patient repeated chest pain, accompanied by a drop in blood pressure and junctional escape rhythm. The highly sensitive cardiac troponin I (hs-cTnI) was raised at 560 ng/L. Coronary angiography showed coronary arteries without significant stenosis. The provocative test with intracoronary ergonovine demonstrated coronary vasospasm of the anterior descending artery accompanied by chest pain, with resolution after intracoronary nitroglycerin. Under amlodipine, nitrate, acetylsalicylic acid, statin and corticosteroids the patient did not experience the recurrence of angina. CONCLUSIONS This case illustrates coronary involvement, manifested as coronary spasm with favorable outcomes, in systemic vasculitis. The underlying mechanism is immune-mediated inflammation in vascular walls.
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Affiliation(s)
- Oana-Mădălina Manole
- Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Department of Cardiology, "St. Spiridon" County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Mihai Ștefan Cristian Haba
- Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Department of Cardiology, "St. Spiridon" County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Iulian-Theodor Matei
- Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Department of Cardiology, "St. Spiridon" County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Viviana Onofrei
- Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Department of Cardiology, "St. Spiridon" County Clinical Emergency Hospital, 700111 Iași, Romania
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12
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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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13
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Iwashima Y, Fukushima H, Nakano N, Horio T, Rai T, Ishimitsu T. Predialysis central arterial waveform and blood pressure changes during hemodialysis. Sci Rep 2024; 14:25768. [PMID: 39468136 PMCID: PMC11519356 DOI: 10.1038/s41598-024-75000-4] [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: 01/04/2024] [Accepted: 10/01/2024] [Indexed: 10/30/2024] Open
Abstract
To investigate the predictive value of the central arterial waveform for intradialytic blood pressure (BP) change, a total of 152 hemodialysis patients (mean age 68 years) on a thrice-weekly hemodialysis schedule were enrolled, and at both the first and second session of the week, BP and central arterial waveform were measured every 30 min during hemodialysis. In both sessions, a 1-standard deviation increase in baseline subendocardial viability ratio (SEVR), an index of subendocardial perfusion, as well as in baseline systolic BP (SBP) was an independent predictor of maximum SBP decrease ≥ 30 mmHg during hemodialysis. When divided into four groups based on the respective median level of SEVR in the SBP ≥ median and SBP < median groups, intradialytic SBP change was different among the subgroups. Multiple logistic regression analysis revealed that, compared with the SBP < median; low SEVR group, the SBP < median; high SEVR group had lower risk, and the SBP ≥ median; low SEVR group had higher risk of SBP decrease ≥ 30 mmHg, but the risk did not differ from that in the SBP ≥ median; high SEVR group. Predialysis subendocardial perfusion evaluated by SEVR was associated with the maximum intradialytic BP decrease, and evaluation of the central arterial waveform could be used as complementary screening for intradialytic BP change.
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Affiliation(s)
- Yoshio Iwashima
- Department of Internal Medicine, Kansai Medical University Kori Hospital, 8-45 Kori Hon-douri chou, Neyagawa, Osaka, Japan.
- Department of Nephrology and Hypertension, Dokkyo Medical University, Mibu, Tochigi, Japan.
| | | | - Nobuyuki Nakano
- Division of Internal Medicine, Clinic of Utsunomiya Jinn-naika-hifuka, Utsunomiya, Tochigi, Japan
| | - Takeshi Horio
- Department of Cardiovascular Medicine, Ishikiriseiki Hospital, Higashiosaka, Osaka, Japan
| | - Tatemitsu Rai
- Department of Nephrology and Hypertension, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Toshihiko Ishimitsu
- Department of Nephrology and Hypertension, Dokkyo Medical University, Mibu, Tochigi, Japan
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14
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El Ayech Boudiche F, Elarbi M, Boudiche S, Sayari T, Ben Jemaa H, Chetoui A, Ben Ahmed H, Ouechtati W, Allouche E, Gargah T, Bezdah L. Changes in echocardiographic parameters after hemodialysis session in a North African pediatric population with end-stage renal disease and without known heart disease. LA TUNISIE MEDICALE 2024; 102:628-634. [PMID: 39441160 PMCID: PMC11574370 DOI: 10.62438/tunismed.v102i10.4967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 07/17/2024] [Indexed: 10/25/2024]
Abstract
INTRODUCTION Children undergoing long-term hemodialysis (HD) face a reduction in life expectancy mostly due to cardiovascular mortality. Effects of HD on cardiac function have not been fully elucidated in pediatric population. AIM This study aimed to assess HD session impact on cardiac function in pediatric patients using conventional and strain echocardiography. METHODS We performed a prospective, comparative study of echocardiographic parameters before and after single HD session in a chronic HD pediatric population. We enrolled between the 1st and 30th September 2023, all consecutive patients with end-stage renal disease (ESRD) aged up to 18 years old on maintenance HD three times weekly for at least three months. All patients underwent conventional and left ventricular (LV) longitudinal strain echocardiography in a window of 30-60 minutes before and after HD. RESULTS 23 patients, 14.8 ± 2.1 years old and 47.8% male, were enrolled. Reductions in body weight and blood pressure were observed after HD, whereas heart rate increased. Significant decrease in LV and left atrial diameters and volumes after HD session were observed. Mitral peak E velocity, as well as average E/e' were significantly lower after HD. Although LV ejection fraction was unchanged, global longitudinal strain for LV was significantly reduced after dialysis (-17.3 ± 3.0% vs. -14.9 ± 2.4%, p=4.10-8). CONCLUSION Patent deterioration in LV systolic function following HD was identified by speckle tracking echocardiography (STE). STE has the potential to unmask early myocardial dysfunction even when there is no evident alteration in conventional systolic function parameters in children with ESRD.
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Affiliation(s)
- Faten El Ayech Boudiche
- Cardiology Department, Charles Nicolle Hospital, Tunis, Tunisia. Faculty of Medicine of Tunis, Tunis El Manar university
| | - Malek Elarbi
- Cardiology Department, Charles Nicolle Hospital, Tunis, Tunisia. Faculty of Medicine of Tunis, Tunis El Manar university
| | - Selim Boudiche
- Cardiology Department, La Rabta Hospital, Tunis, Tunisia. Faculty of Medicine of Tunis, Tunis El Manar university
| | - Taha Sayari
- Pediatrics department, Charles Nicolle Hospital, Tunis, Tunisia. Faculty of Medicine of Tunis, Tunis El Manar university
| | - Hakim Ben Jemaa
- Cardiology Department, Charles Nicolle Hospital, Tunis, Tunisia. Faculty of Medicine of Tunis, Tunis El Manar university
| | - Ahmed Chetoui
- Cardiology Department, Charles Nicolle Hospital, Tunis, Tunisia. Faculty of Medicine of Tunis, Tunis El Manar university
| | - Habib Ben Ahmed
- Cardiology Department, Charles Nicolle Hospital, Tunis, Tunisia. Faculty of Medicine of Tunis, Tunis El Manar university
| | - Wejdene Ouechtati
- Cardiology Department, Charles Nicolle Hospital, Tunis, Tunisia. Faculty of Medicine of Tunis, Tunis El Manar university
| | - Emna Allouche
- Cardiology Department, Charles Nicolle Hospital, Tunis, Tunisia. Faculty of Medicine of Tunis, Tunis El Manar university
| | - Tahar Gargah
- Pediatrics department, Charles Nicolle Hospital, Tunis, Tunisia. Faculty of Medicine of Tunis, Tunis El Manar university
| | - Leila Bezdah
- Cardiology Department, Charles Nicolle Hospital, Tunis, Tunisia. Faculty of Medicine of Tunis, Tunis El Manar university
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15
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Zhang Q, Wang X, Chao Y, Liu L. Focus on oliguria during renal replacement therapy. J Anesth 2024; 38:681-691. [PMID: 38777933 PMCID: PMC11415420 DOI: 10.1007/s00540-024-03342-4] [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: 06/08/2023] [Accepted: 04/29/2024] [Indexed: 05/25/2024]
Abstract
Oliguria is a clinical symptom characterized by decreased urine output, which can occur at any stage of acute kidney injury and also during renal replacement therapy. In some cases, oliguria may resolve with adjustment of blood purification dose or fluid management, while in others, it may suggest a need for further evaluation and intervention. It is important to determine the underlying cause of oliguria during renal replacement therapy and to develop an appropriate treatment plan. This review looks into the mechanisms of urine production to investigate the mechanism of oliguria during renal replacement therapy from two aspects: diminished glomerular filtration rate and tubular abnormalities. The above conditions all implying a renal oxygen supply-demand imbalance, which is the signal of worsening kidney injury. It also proposes a viable clinical pathway for the treatment and management of patients with acute kidney injury receiving renal replacement therapy.
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Affiliation(s)
- Qian Zhang
- Department of Intensive Care Unit (ICU), The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, 550004, People's Republic of China
| | - Xiaoting Wang
- Department of Intensive Care Unit (ICU), Peking Union Medical College Hospital, Beijing, 100005, People's Republic of China
| | - Yangong Chao
- Department of Intensive Care Unit (ICU), The First Affiliated Hospital of Tsinghua University, Beijing, 100016, People's Republic of China
| | - Lixia Liu
- Department of Intensive Care Unit (ICU), The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, People's Republic of China.
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16
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Guo Y, Tan X, Li Z, Dai C, Yang Q, Nie Y, Cao X, Shu X, Pan C, Sun M. Global left ventricular myocardial work: A novel method to assess left ventricular myocardial function and predict major adverse cardiovascular events in maintenance hemodialysis patients. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:1019-1028. [PMID: 38934699 DOI: 10.1002/jcu.23750] [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: 01/26/2024] [Revised: 04/23/2024] [Accepted: 05/25/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The application value of myocardial work (MW) in evaluating myocardial function and predicting major adverse cardiovascular events (MACE) in maintenance hemodialysis (MHD) patients has not been fully explored. PURPOSE Comparing noninvasive MW parameters between MHD patients and healthy controls, and further determining its value in predicting MACE in MHD patients. METHODS A prospective single-institution study included 92 MHD patients without prior cardiovascular disease and 40 age- and sex-matched healthy controls. Conventional echocardiographic data, global longitudinal strain (GLS), and MW parameters (global work index [GWI], global constructive work [GCW], global work efficiency [GWE], global wasted work [GWW]) were derived and compared between MHD and the control. Logistic regression was used to determine the predictive value of these parameters for MACE. The receiver operating characteristic curve was utilized to compare the predictive differences of MACE between GWE and GLS. RESULTS Compared with healthy individuals, MHD patients had significantly reduced GWE, GLS and elevated LVMI, GWW (all p < 0.001), while there was no significant difference in left ventricular ejection fraction. Twenty eight (30%) MHD patients experienced MACE. Two nested models adding GWE and GLS, respectively, showed that age (p < 0.005), GWE (p = 0.034), and GLS (p = 0.014) were independent predictors of MACE. The AUC derived from GWE for predicting MACE was significantly higher than that derived from GLS (0.836 vs. 0.743, p = 0.039). CONCLUSIONS Myocardial work is a novel tool for assessing left ventricular myocardial performance in MHD patients. GWE is an independent predictor of MACE.
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Affiliation(s)
- Yao Guo
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Xiao Tan
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zheng Li
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Chenchen Dai
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qiang Yang
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuxin Nie
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xuesen Cao
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xianhong Shu
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Cuizhen Pan
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Minmin Sun
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
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17
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Yokoi M, Ito T, Suzuki W, Yamamoto J, Nakayama T, Ichihashi T, Kikuchi S, Kitada S, Goto T, Seo Y. Hemodialysis-induced Myocardial Stunning with No Obstructive Coronary Artery Disease: Pathophysiological Significance of Coronary Microvascular Dysfunction. Intern Med 2024; 63:2023-2026. [PMID: 38044153 PMCID: PMC11309868 DOI: 10.2169/internalmedicine.2388-23] [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] [Received: 06/01/2023] [Accepted: 09/28/2023] [Indexed: 12/05/2023] Open
Abstract
Hemodialysis (HD)-induced myocardial stunning, characterized by transient left ventricular systolic dysfunction during HD, has been reported to be common and associated with a poor prognosis. However, the pathophysiology is not fully understood. We herein report a case of HD-induced myocardial stunning without obstructive coronary artery disease complicated by coronary microvascular dysfunction (CMD), suggesting that CMD plays a crucial role in the pathophysiology of this disease.
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Affiliation(s)
- Masashi Yokoi
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Tsuyoshi Ito
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Wataru Suzuki
- Department of Cardiology, Aichi Medical University, Japan
| | - Junki Yamamoto
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Takafumi Nakayama
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Taku Ichihashi
- Department of Cardiology, Nagoya City University East Medical Center, Japan
| | - Shohei Kikuchi
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Shuichi Kitada
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Toshihiko Goto
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Japan
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18
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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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19
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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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20
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McIntyre CW. Update on Hemodialysis-Induced Multiorgan Ischemia: Brains and Beyond. J Am Soc Nephrol 2024; 35:653-664. [PMID: 38273436 PMCID: PMC11149050 DOI: 10.1681/asn.0000000000000299] [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: 06/30/2023] [Accepted: 12/17/2023] [Indexed: 01/27/2024] Open
Abstract
Hemodialysis is a life-saving treatment for patients with kidney failure. However, patients requiring hemodialysis have a 10-20 times higher risk of cardiovascular morbidity and mortality than that of the general population. Patients encounter complications such as episodic intradialytic hypotension, abnormal perfusion to critical organs (heart, brain, liver, and kidney), and damage to vulnerable vascular beds. Recurrent conventional hemodialysis exposes patients to multiple episodes of circulatory stress, exacerbating and being aggravated by microvascular endothelial dysfunction. This promulgates progressive injury that leads to irreversible multiorgan injury and the well-documented higher incidence of cardiovascular disease and premature death. This review aims to examine the underlying pathophysiology of hemodialysis-related vascular injury and consider a range of therapeutic approaches to improving outcomes set within this evolved rubric..
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Affiliation(s)
- Christopher W McIntyre
- Lilibeth Caberto Kidney Clinical Research Unit, Lawson Health Research Institute, London, Ontario, Canada, and Departments of Medicine, Medical Biophysics and Pediatrics, Western University, London, Ontario, Canada
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Maufrais C, Josse M, Patrier L, Grandperrin A, Isnard M, Turc-Baron C, Nottin S, Mandigout S, Cristol JP, Obert P. Cardioprotective effect of intradialytic exercise on left atrial mechanics. Am J Physiol Renal Physiol 2024; 326:F694-F703. [PMID: 38511221 DOI: 10.1152/ajprenal.00380.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 03/01/2024] [Accepted: 03/14/2024] [Indexed: 03/22/2024] Open
Abstract
Left atrial (LA) function plays a pivotal role in cardiac performance by modulating left ventricular (LV) function. Impairments in LV function are commonly reported during hemodialysis (HD), but available data describing changes in LA function are limited. There is growing evidence of the cardioprotective effect of intradialytic exercise (IDE) on LV function, but studies analyzing its effect on LA function are scarce. Our aim was to evaluate whether IDE can limit the severity of HD-induced impairment in LA myocardial function. In this prospective, open-label, two-center randomized crossover trial, 56 stable individuals receiving HD participated in 2 HD sessions in random order: standard HD and a session incorporating 30 min of aerobic exercise. LA and LV global longitudinal strains (GLSs) were obtained before and at peak stress of HD (i.e., 30 min before the HD ending). IDE totally eradicated the decline in LA reservoir strain observed during HD (estimated difference: 3.1%, 95% confidence interval: 0.4/5.8, P = 0.02), whereas it did not affect the other components of LA mechanics. A similar result favoring IDE intervention was also demonstrated on GLS changes over the HD procedure (P < 0.001). Between-session differences of changes in GLS and LA reservoir strain were correlated (r = -0.32, P = 0.03). The cardioprotective effect of IDE disappeared in patients with LA enlargement (i.e., LA volume index >34 mL/m2). In conclusion, even a short duration of IDE at moderate intensity is effective in preventing HD-associated decline in LA reservoir function. Further research is needed to explore the long-term benefits of IDE on LA function.NEW & NOTEWORTHY A single bout of intradialytic exercise (IDE) at moderate intensity can prevent the hemodialysis-associated decline in left atrial (LA) function. This was partially explained by the relative preservation of left ventricular systolic function with IDE. Benefits of IDE on LA function were lost in patients with LA dilation. Further studies are needed to explore the mechanisms behind IDE-induced cardioprotection and evaluate the clinical impacts of the repetitive cardioprotective effects of IDE on LA function.
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Affiliation(s)
- Claire Maufrais
- UPR4278 Laboratoire de Physiologie Expérimentale Cardiovasculaire, Avignon University, Avignon, France
| | - Matthieu Josse
- UPR4278 Laboratoire de Physiologie Expérimentale Cardiovasculaire, Avignon University, Avignon, France
| | - Laure Patrier
- Fondation Charles Mion-AIDER Santé, Grabels, France
- Centre Hospitalier Universitaire, Nîmes, France
| | - Antoine Grandperrin
- UPR4278 Laboratoire de Physiologie Expérimentale Cardiovasculaire, Avignon University, Avignon, France
| | - Myriam Isnard
- Association pour le Traitement de l'Insuffisance Rénale Avignon, Avignon, France
| | - Cécile Turc-Baron
- Fondation Charles Mion-AIDER Santé, Grabels, France
- Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Stéphane Nottin
- UPR4278 Laboratoire de Physiologie Expérimentale Cardiovasculaire, Avignon University, Avignon, France
| | | | - Jean-Paul Cristol
- Fondation Charles Mion-AIDER Santé, Grabels, France
- Centre Hospitalier Universitaire de Montpellier, Montpellier, France
- PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Philippe Obert
- UPR4278 Laboratoire de Physiologie Expérimentale Cardiovasculaire, Avignon University, Avignon, France
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22
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Pol Heres SV, Aresté Fosalba N, Barragán-Prieto A, Aguilera Morales WA, Salgueira M. COVID 19 and myoclonus, do hemodialysis patients have more risk? Nefrologia 2024; 44:284-286. [PMID: 38614889 DOI: 10.1016/j.nefroe.2024.03.015] [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: 04/15/2024] Open
Abstract
We discuss two recent cases from our hospital in which two patients with ESKD receiving periodical hemodialysis (HD) and SarS-Cov-2 infection suffered movement disorders, being the onset related to the HD sessions in both. First case is a 78 year-old woman who is admitted with generalized myoclonic status epilepticus and second case is a 46 year-old male who starts repeatedly suffering myoclonus during his hemodialysis sessions on day +10 after testing positive (asymptomatic infection). There are two main hypotheses when it comes to myoclonus and CNS disorders in COVID19, post-hypoxic origin and inmunomediated postinfectious origin. We wonder if they could both be interacting in patients with kidney disease, and especially in those who receive hemodialysis, maximizing the risk of suffering this type of disorders.
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Affiliation(s)
| | - Nuria Aresté Fosalba
- Servicio de Nefrología del Hospital Universitario Virgen Macarena, Sevilla, Spain
| | | | | | - Mercedes Salgueira
- Servicio de Nefrología del Hospital Universitario Virgen Macarena, Sevilla, Spain
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23
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Verrelli D, Sharma A, Alexiuk J, Tays Q, Rossum K, Sharma M, Ford E, Iansavitchene A, Al-Jaishi AA, Whitlock R, McIntyre CW, Garg AX, Bohm C. Effect of Intradialytic Exercise on Cardiovascular Outcomes in Maintenance Hemodialysis: A Systematic Review and Meta-Analysis. KIDNEY360 2024; 5:390-413. [PMID: 38306116 PMCID: PMC11000728 DOI: 10.34067/kid.0000000000000361] [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: 08/24/2023] [Accepted: 01/11/2024] [Indexed: 02/03/2024]
Abstract
Key Points Individuals receiving hemodialysis have high rates of cardiovascular disease not explained by traditional cardiovascular risk factors. Intradialytic exercise improves cardiovascular outcomes, including arterial resistance, BP, and heart rate variability. Clinicians should consider including intradialytic aerobic exercise programs in hemodialysis care to supplement broader treatment plans. Background Cardiovascular disease is the leading cause of death among people with kidney failure on hemodialysis, for whom improving cardiovascular health is a research priority. Intradialytic myocardial stunning is common and associated with adverse cardiovascular events. Intradialytic exercise may mitigate intradialytic myocardial stunning and improve cardiovascular structure and function. This systematic review investigated the effect of intradialytic exercise on cardiovascular outcomes in adults undergoing maintenance hemodialysis (PROSPERO CRD42018103118). Methods Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we systematically searched MEDLINE, Embase, Cochrane CENTRAL, SportDiscus, and PEDro databases from 1960 until June 2022, for randomized and nonrandomized studies investigating the effect of intradialytic exercise programs on objective cardiovascular outcomes, prespecified as primary or secondary outcomes. The primary outcome was arterial resistance. Results Of 10,837 references identified, 32 met eligibility criteria. These studies investigated the effect of intradialytic exercise on arterial resistance (eight studies), BP (20 studies), myocardial structure and function (seven studies), endothelial function (two studies), sympathetic overactivity (nine studies), biomarkers of cardiac injury (three studies), and cardiovascular hospitalization and mortality (two studies). Most studies used aerobic exercise as the intervention and usual care (no exercise) controls. Meta-analysis of intradialytic exercise versus usual care resulted in a statistically significant reduction in arterial resistance measured by pulse wave velocity with mean difference −1.63 m/s (95% confidence interval, −2.51 to −0.75). Meta-analyses for diastolic BP, left ventricular ejection fraction, and low-frequency/high-frequency ratio measure of heart rate variability also showed statistically significant improvements with exercise. There was no significant difference in change in systolic BP, augmentation index, and left ventricular mass index between groups. Conclusions Intradialytic exercise programming resulted in a clinically meaningful improvement to pulse wave velocity, a component of arterial resistance. Improvements in several physiologic measures of cardiovascular health, including diastolic BP, left ventricular ejection fraction, and heart rate variability measured by the low-frequency/high-frequency ratio were also observed. The effects of intradialytic exercise on major adverse cardiovascular events remains uncertain.
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Affiliation(s)
- Davide Verrelli
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ajaya Sharma
- Institute for Clinical Evaluative Sciences, University of Western Ontario, London, Ontario, Canada
| | - Jamie Alexiuk
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Quinn Tays
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Krista Rossum
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Monica Sharma
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Emilie Ford
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Alla Iansavitchene
- Corporate Academics, Health Sciences Library, London Health Sciences Centre, London, Ontario, Canada
| | - Ahmed A. Al-Jaishi
- Institute for Clinical Evaluative Sciences, University of Western Ontario, London, Ontario, Canada
| | - Reid Whitlock
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Christopher W. McIntyre
- Institute for Clinical Evaluative Sciences, University of Western Ontario, London, Ontario, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Amit X. Garg
- Institute for Clinical Evaluative Sciences, University of Western Ontario, London, Ontario, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Clara Bohm
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
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24
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Borkum M, Levin A, Ficocelli J, Wone L, Kiaii M. A Current State of the Art and Science of Exercise in Dialysis: A Narrative Review. Can J Kidney Health Dis 2024; 11:20543581241229253. [PMID: 38370309 PMCID: PMC10874151 DOI: 10.1177/20543581241229253] [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: 06/15/2023] [Indexed: 02/20/2024] Open
Abstract
Purpose of the review The purpose of the review is to discuss current proven benefits and problems of integrating exercise in the care of people receiving dialysis by reviewing literature from the last few years and identifying important questions that still need to be asked and answered. Methods A focused review and appraisal of the literature were done. Original peer-reviewed articles, review articles, opinion pieces and guidelines were identified from PubMed and Google Scholar databases. Only sources in English were accessed. Search terms "exercise" and "dialysis" were used to find active recruiting randomized trials in various clinical trial registry platforms. Key findings Numerous studies have demonstrated the benefits of exercise training in individuals receiving dialysis, limited by factors such as short duration of follow-up and inconsistent adverse event reporting and outcomes selected. Notable gaps in exercise research in dialysis include ways to maintain programs and patient motivation, studies in peritoneal dialysis and home hemodialysis patients, and how best to define and measure outcomes of interest. Implications This review summarizes the current state of exercise in people receiving dialysis and serves as a call to action to conduct large, randomized controlled trials to improve the quality of evidence needed to implement and sustain innovative, exercise interventions, and programs for this population.
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Affiliation(s)
- Megan Borkum
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
- BC Renal, Vancouver, BC, Canada
| | - Adeera Levin
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
- BC Renal, Vancouver, BC, Canada
| | - Joey Ficocelli
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
| | | | - Mercedeh Kiaii
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
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25
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Gullapudi VRL, Cox EF, Buchanan CE, Canaud B, White K, Taal MW, Selby NM, Francis ST. Randomized trial comparing standard versus thermocontrolled haemodialysis using intradialytic cardiac, brain and renal magnetic resonance imaging. Nephrol Dial Transplant 2024; 39:233-241. [PMID: 37433572 PMCID: PMC10828207 DOI: 10.1093/ndt/gfad150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Ischaemic end-organ damage during haemodialysis (HD) is a significant problem that may be ameliorated by intradialytic cooling. A randomised trial was performed to compare standard HD (SHD; dialysate temperature 37°C) and programmed cooling of the dialysate [thermocontrolled HD (TCHD)] using multiparametric magnetic resonance imaging (MRI) to assess structural, functional and blood flow changes in the heart, brain and kidneys. METHODS Prevalent HD patients were randomly allocated to receive either SHD or TCHD for 2 weeks before undergoing serial MRI at four time points: pre-, during (30 min and 180 min) and post-dialysis. MRI measures include cardiac index, myocardial strain, longitudinal relaxation time (T1), myocardial perfusion, internal carotid and basilar artery flow, grey matter perfusion and total kidney volume. Participants then crossed to the other modality to repeat the study protocol. RESULTS Eleven participants completed the study. Separation in blood temperature between TCHD (-0.1 ± 0.3°C) and SHD (+0.3 ± 0.2°C; P = .022) was observed, although there was no difference in tympanic temperature changes between arms. There were significant intradialytic reductions in cardiac index, cardiac contractility (left ventricular strain), left carotid and basilar artery blood flow velocities, total kidney volume, longitudinal relaxation time (T1) of the renal cortex and transverse relaxation rate (T2*) of the renal cortex and medulla, but no differences between arms. Pre-dialysis T1 of the myocardium and left ventricular wall mass index were lower after 2 weeks of TCHD compared with SHD [1266 ms (interquartile range 1250-1291) versus 1311 ± 58 ms, P = .02; 66 ± 22 g/m2 versus 72 ± 23 g/m2, P = .004]. CONCLUSIONS HD adversely affects cardiac function, reduces carotid and basilar artery blood flow and total kidney volume, but mild dialysate cooling using a biofeedback module did not result in differences in intradialytic MRI measures compared with SHD.
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Affiliation(s)
- Venkata R Latha Gullapudi
- Centre for Kidney Research and Innovation, University of Nottingham, Derby, UK
- Department of Renal Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Eleanor F Cox
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Charlotte E Buchanan
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham, UK
| | - Bernard Canaud
- Global Medical Office, Fresenius Medical Care, Bad Homburg, Germany
| | - Kelly White
- Department of Renal Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Maarten W Taal
- Centre for Kidney Research and Innovation, University of Nottingham, Derby, UK
- Department of Renal Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, University of Nottingham, Derby, UK
- Department of Renal Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Susan T Francis
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
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26
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Roskal-Wałek J, Gołębiewska J, Mackiewicz J, Wałek P, Bociek A, Biskup M, Odrobina D, Jaroszyński A. The Haemodialysis Session Effect on the Choroidal Thickness and Retinal and Choroidal Microcirculation-A Literature Review. J Clin Med 2023; 12:7729. [PMID: 38137798 PMCID: PMC10743986 DOI: 10.3390/jcm12247729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Haemodialysis (HD) is currently the most commonly used method of renal replacement therapy. The process of dialysis involves numerous changes that affect many systems, including the eye. The changes occurring in the course of HD may affect the ocular parameters, such as intraocular pressure, central corneal thickness, retinal thickness, retinal nerve fibre layer thickness, and choroidal thickness (CT). The choroid, being one of the most vascularized tissues, is characterized by the highest ratio of blood flow to tissue volume in the entire body, may be particularly susceptible to changes occurring during HD, and at the same time reflect the microcirculatory status and its response to HD. Patients with end-stage renal disease subjected to dialysis are highly susceptible to systemic microvascular dysfunction. Moreover, it is considered that the process of HD itself contributes to vascular dysfunction. Nowadays, thanks to the development of imaging techniques, the widely available optical coherence tomography (OCT) tests allow for the assessment of CT, while OCT-angiography allows for a quick, non-invasive, and repeatable assessment of the condition of retinal and choroidal microcirculation, which significantly expands our knowledge regarding the reaction of ocular microcirculation due to HD. The assessment of both retinal and choroidal circulation is even more attractive because retinal circulation is autoregulated, while choroidal circulation is mainly controlled by extrinsic autonomic innervation. Thus, assessment of the choroidal response to an HD session may provide the possibility to indirectly evaluate the functions of the autonomic system in patients subjected to HD. At a time when the importance of microcirculation in systemic and renal diseases is becoming increasingly evident, the assessment of ocular microcirculation appears to be a potential biomarker for assessing the condition of systemic microcirculation. In this work, we present a review of the literature on the effect of the HD session on CT and the retinal and choroidal microcirculation.
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Affiliation(s)
- Joanna Roskal-Wałek
- Ophthalmology Clinic, Voivodeship Regional Hospital, 25-736 Kielce, Poland;
- Collegium Medicum, Jan Kochanowski University, 25-317 Kielce, Poland; (P.W.); (A.B.); (D.O.); (A.J.)
| | - Joanna Gołębiewska
- Department of Ophthalmology, Military Institute of Aviation Medicine, 01-755 Warsaw, Poland;
- Medical Faculty, Lazarski University, 02-662 Warsaw, Poland
| | - Jerzy Mackiewicz
- Department of Vitreoretinal Surgery, Medical University of Lublin, 20-079 Lublin, Poland;
| | - Paweł Wałek
- Collegium Medicum, Jan Kochanowski University, 25-317 Kielce, Poland; (P.W.); (A.B.); (D.O.); (A.J.)
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
| | - Agnieszka Bociek
- Collegium Medicum, Jan Kochanowski University, 25-317 Kielce, Poland; (P.W.); (A.B.); (D.O.); (A.J.)
| | - Michał Biskup
- Ophthalmology Clinic, Voivodeship Regional Hospital, 25-736 Kielce, Poland;
| | - Dominik Odrobina
- Collegium Medicum, Jan Kochanowski University, 25-317 Kielce, Poland; (P.W.); (A.B.); (D.O.); (A.J.)
- Ophthalmology Clinic Boni Fratres Lodziensis, 93-357 Łódź, Poland
| | - Andrzej Jaroszyński
- Collegium Medicum, Jan Kochanowski University, 25-317 Kielce, Poland; (P.W.); (A.B.); (D.O.); (A.J.)
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27
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Wan M, Yu J, Liu Y, Wang Y, Qiu Y, Yi C, He W, Yang X, Guo Q, Liu D. Left ventricular strain and myocardial work in short-term peritoneal dialysis patients. Ren Fail 2023; 45:2284838. [PMID: 38017695 PMCID: PMC11001367 DOI: 10.1080/0886022x.2023.2284838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 11/13/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Initiation of dialysis encompasses new cardiovascular challenges on patients with end-stage renal disease (ESRD). This study used two-dimensional speckle-tracking echocardiography (2D-STE) to investigate the change of left ventricular (LV) myocardial function undergoing peritoneal dialysis (PD) within 1-3 months. METHODS A total of 56 patients with ESRD and 27 healthy controls were enrolled in this prospective study. Mean duration of PD was 44.41 ± 16.44 days. We evaluated LV myocardial function of patients with ESRD in baseline and within 1-3 months after PD by 2D-STE with global longitudinal strains (GLS) and myocardial work (MW). Based on the level of serum phosphate before PD, patients were divided into two groups: the group with normal serum phosphate or hyperphosphatemia. RESULTS Compared with healthy controls, patients with ESRD had impaired GLS (p < .001) and increased global work index (GWI) (p = .034), global constructive work (GCW) (p < .001), global wasted work (GWW) (p < .001), and lower global work efficiency (GWE) (p = .002). After PD therapy, GWI (p = .001), GCW (p < .001), and GWW (p = .023) decreased and closed to healthy subjects (p > .05) and no significant improvement was observed in GLS (p = .387). GLS of basal segments worsened in the hyperphosphatemia group (p = .005) and GWW reduced remarkably in the group with normal serum phosphate after PD treatment (p = .008). The change of left ventricular internal diameter in diastole (LVIDd) was the only parameter influenced GWI in post-dialysis patients (β = 0.324, p = .013). CONCLUSIONS Short-term PD treatment improved LV MW in ESRD patients. They benefited more when receiving treatment before the increase of serum phosphorus.
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Affiliation(s)
- Minjie Wan
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jianwen Yu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Yanqiu Liu
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yan Wang
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yagui Qiu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Chunyan Yi
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Wei He
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiao Yang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Qunying Guo
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Donghong Liu
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Sansom B, Udy A, Presneill J, Bellomo R. Early Net Ultrafiltration during Continuous Renal Replacement Therapy: Impact of Admission Diagnosis and Association with Mortality. Blood Purif 2023; 53:170-180. [PMID: 37992695 PMCID: PMC10911164 DOI: 10.1159/000535315] [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: 04/27/2023] [Accepted: 11/12/2023] [Indexed: 11/24/2023]
Abstract
INTRODUCTION Continuous renal replacement therapy (CRRT) is common in the intensive care unit (ICU) but a high net ultrafiltration rate (UFNET) calculated with daily data may increase mortality. We aimed to study early UFNET practice using minute-by-minute CRRT machine recordings and to assess its association with admission diagnosis and mortality. METHODS We studied CRRT treatments in three adult ICUs over 7 years. We calculated early UFNET rates minute-by-minute and categorized UFNET into tertiles of mean UFNET in the first 72 h and admission diagnosis. We applied Cox-proportional hazards modelling with censoring of patients who died within 72 h. RESULTS We studied 1,218 patients, 154,712 h, and 9,282,729 min of CRRT (5,702 circuits). Mean early UFNET was 1.52 (1.46-1.57) mL/kg/h. Early UFNET tertiles were similar to, but somewhat higher than, previously reported values at 0.00-1.20 mL/kg/h, 1.21-1.93 mL/kg/h, and >1.93 mL/kg/h. UFNET values were similar whether evaluated at 24 or 72 h or for the entire duration of CRRT. There was, however, significant variation in UFNET practice by admission diagnosis: higher in respiratory diseases (pneumonia p = 0.01, other p < 0.0001) and cardiovascular disease (p = 0.005) but lower in cardiothoracic surgery (p = 0.04), renal (p = 0.0003) and toxicology-associated diagnoses (p = 0.01). Higher UFNET was associated with an increased hazard of death, HR 1.24 (1.13-1.37), independent of admission diagnosis, weight, age, sex, presence of end-stage kidney disease, and severity of illness. CONCLUSION Early UFNET practice varies significantly by admission diagnosis. Higher early UFNET is independently associated with mortality. Impacts of UFNET on mortality may vary by admission diagnosis. Further work is required to elucidate the nature and mechanisms responsible for this association.
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Affiliation(s)
- Benjamin Sansom
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia,
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia,
| | - Andrew Udy
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey Presneill
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Melbourne, Victoria, Australia
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29
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Thompson S, Stickland MK, Wilund K, Gyenes GT, Bohm C. Exercise Rehabilitation for People With End-Stage Kidney Disease: Who Will Fill the Gaps? Can J Cardiol 2023; 39:S335-S345. [PMID: 37597748 DOI: 10.1016/j.cjca.2023.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023] Open
Abstract
Exercise rehabilitation is a well established therapy for reducing morbidity and mortality and improving quality of life and function across chronic conditions. People with dialysis-dependent kidney failure have a high burden of comorbidity and symptoms, commonly characterised as fatigue, dyspnoea, and the inability to complete daily activities. Despite more than 30 years of exercise research in people with kidney disease and its established benefit in other chronic diseases, exercise programs are rare in kidney care and are not incorporated into routine management at any stage. In this review, we describe the mechanisms contributing to exercise intolerance in those with end-stage kidney disease and outline the role of exercise rehabilitation in addressing the major challenges to kidney care: cardiovascular disease, symptom burden, and physical frailty. We also draw on existing models of exercise rehabilitation from other chronic conditions to inform the way forward and challenge the status quo of exercise rehabilitation in both practice and research.
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Affiliation(s)
- Stephanie Thompson
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | | | - Kenneth Wilund
- Department of Kinesiology and Community Health, University of Illinois, Urbana, Illinois, USA
| | - Gabor T Gyenes
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Clara Bohm
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
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Anaya AB, Lee MM, Neu AM, Swartz SM, Geer JJ, Warady BA. Standardizing Blood Pressure Measurements in Pediatric Hemodialysis: a Collaborative Journey. Curr Hypertens Rep 2023; 25:329-334. [PMID: 37505377 DOI: 10.1007/s11906-023-01255-3] [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] [Accepted: 06/30/2023] [Indexed: 07/29/2023]
Abstract
PURPOSE OF REVIEW This manuscript details the development and execution of a quality improvement (QI) initiative aimed at standardizing blood pressure (BP) measurement practices in pediatric hemodialysis (HD) units across a national dialysis collaborative. RECENT FINDINGS Although there are recommendations for the detection and treatment of hypertension in the pediatric population, currently there is no data or recommendations specific to the methodology of measuring blood pressure in a pediatric hemodialysis setting. In 2016, the Standardizing Care to Improve Outcomes in Pediatric End Stage Kidney Disease (SCOPE) Collaborative assembled a dedicated working group to thoroughly examine BP measurement practices across participating pediatric HD centers and, drawing from current research, to establish a standardized best practice for BP measurement in pediatric HD patients both in-center and at home. Employing QI methodology, the working group devised a standardized "BP Bundle" and implemented it throughout the SCOPE Collaborative. This work led to successful practice improvement by establishing a consistent approach to BP measurement in pediatric HD patients cared for in SCOPE centers. With a standard best practice now in place and over 85% compliance with the BP Bundle across the SCOPE Collaborative, researchers and healthcare professionals can more accurately study and ultimately enhance the cardiovascular health of pediatric HD patients.
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Affiliation(s)
- Audrey B Anaya
- UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Marsha M Lee
- UCSF Benioff Children's Hospital, San Francisco, CA, USA
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Ishibashi Y, Zhang S, Tamura S, Ishii H. Brugada phenocopy with altered ST-segment elevation in pericardial diffuse large B-cell lymphoma and effusive-constrictive pericarditis: a case report. Eur Heart J Case Rep 2023; 7:ytad463. [PMID: 37854103 PMCID: PMC10580269 DOI: 10.1093/ehjcr/ytad463] [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: 04/18/2023] [Revised: 08/26/2023] [Accepted: 09/11/2023] [Indexed: 10/20/2023]
Abstract
Background Cardiac lymphoma is a rare disease. Effusive-constrictive pericarditis can be a characteristic of pericardial involvement in patients with this disease. Conversely, a phenotype with electrocardiogram changes similar to those of Brugada syndrome is called Brugada phenocopy, and these changes improve after treatment. Case summary A 71-year-old man was transported to our hospital with chest pain, hypotension, and ST-segment elevation in V1 and V2 leads during maintenance dialysis for renal failure. After arrival at the hospital, his ST-segment elevation disappeared, and emergency coronary angiography scan revealed no significant coronary artery stenoses or obstructions. His computed tomography and echocardiography scans revealed pericardial effusion and an intrapericardial mass. Further, his blood pressure dropped and ST-segment elevation recurred during dialysis after 7 days. Thus, pericardiocentesis was performed, but haemodynamic improvement was insufficient, and right catheterization findings suggested effusive-constrictive pericarditis. Meanwhile, flow cytometry of the pericardial fluid suggested the diagnosis of B-cell lymphoma; however, radical chemoradiotherapy was impossible because of cardiogenic shock. The patient died on Day 17. Further, autopsy revealed diffuse large B-cell lymphoma with pericardial and myocardial infiltration. Discussion Cardiac lymphoma is rare but can be associated with effusive-constrictive pericarditis, which may be difficult to manage even with pericardial drainage. In such cases, radical treatment, including chemotherapy, should be promptly considered, if possible. Our patient presented with Brugada-type electrocardiogram but no syncope or family history, suggesting Brugada phenocopy and not true Brugada syndrome due to cardiac lymphoma. Notably, temporary improvement in ST-segment elevation was observed despite the absence of treatment.
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Affiliation(s)
- Yohei Ishibashi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-15, Showa Maebashi, Gunma 371-8511, Japan
- Department of Cardiology, National Hospital Organization Takasaki General Medical Center, 36, Takamatsu Takasaki, Gunma 370-0829, Japan
| | - Shanshan Zhang
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-15, Showa Maebashi, Gunma 371-8511, Japan
| | - Shuntaro Tamura
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-15, Showa Maebashi, Gunma 371-8511, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-15, Showa Maebashi, Gunma 371-8511, Japan
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Josse M, Patrier L, Isnard M, Turc-Baron C, Grandperrin A, Nottin S, Mandigout S, Cristol JP, Maufrais C, Obert P. Cardioprotective Effect of Acute Intradialytic Exercise: A Comprehensive Speckle-Tracking Echocardiography Analysis. J Am Soc Nephrol 2023; 34:1445-1455. [PMID: 37071035 PMCID: PMC10400099 DOI: 10.1681/asn.0000000000000149] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/30/2023] [Indexed: 04/19/2023] Open
Abstract
SIGNIFICANCE STATEMENT Hemodialysis (HD) can lead to acute left ventricular (LV) myocardial wall motion abnormalities (myocardial stunning) due to segmental hypoperfusion. Exercise during dialysis is associated with favorable effects on central hemodynamics and BP stability, factors considered in the etiology of HD-induced myocardial stunning. In a speckle-tracking echocardiography analysis, the authors explored effects of acute intradialytic exercise (IDE) on LV regional myocardial function in 60 patients undergoing HD. They found beneficial effects of IDE on LV longitudinal and circumferential function and on torsional mechanics, not accounted for by cardiac loading conditions or central hemodynamics. These findings support the implementation of IDE in people with ESKD, given that LV transient dysfunction imposed by repetitive HD may contribute to heart failure and increased risk of cardiac events in such patients. BACKGROUND Hemodialysis (HD) induces left ventricular (LV) transient myocardial dysfunction. A complex interplay between linear deformations and torsional mechanics underlies LV myocardial performance. Although intradialytic exercise (IDE) induces favorable effects on central hemodynamics, its effect on myocardial mechanics has never been comprehensively documented. METHODS To evaluate the effects of IDE on LV myocardial mechanics, assessed by speckle-tracking echocardiography, we conducted a prospective, open-label, two-center randomized crossover trial. We enrolled 60 individuals with ESKD receiving HD, who were assigned to participate in two sessions performed in a randomized order: standard HD and HD incorporating 30 minutes of aerobic exercise (HDEX). We measured global longitudinal strain (GLS) at baseline (T0), 90 minutes after HD onset (T1), and 30 minutes before ending HD (T2). At T0 and T2, we also measured circumferential strain and twist, calculated as the net difference between apical and basal rotations. Central hemodynamic data (BP, cardiac output) also were collected. RESULTS The decline in GLS observed during the HD procedure was attenuated in the HDEX sessions (estimated difference, -1.16%; 95% confidence interval [95% CI], -0.31 to -2.02; P = 0.008). Compared with HD, HDEX also demonstrated greater improvements from T0 to T2 in twist, an important component of LV myocardial function (estimated difference, 2.48°; 95% CI, 0.30 to 4.65; P = 0.02). Differences in changes from T0 to T2 for cardiac loading and intradialytic hemodynamics did not account for the beneficial effects of IDE on LV myocardial mechanics kinetics. CONCLUSIONS IDE applied acutely during HD improves regional myocardial mechanics and might warrant consideration in the therapeutic approach for patients on HD.
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Affiliation(s)
- Matthieu Josse
- UPR4278 Laboratory of Experimental Cardiovascular Physiology, Avignon University, Avignon, France
| | - Laure Patrier
- Fondation Charles Mion – AIDER Santé, Grabels, France
- CHU Nîmes, Nîmes, France
| | | | - Cécile Turc-Baron
- Fondation Charles Mion – AIDER Santé, Grabels, France
- CHRU, Montpellier, France
| | - Antoine Grandperrin
- UPR4278 Laboratory of Experimental Cardiovascular Physiology, Avignon University, Avignon, France
| | - Stéphane Nottin
- UPR4278 Laboratory of Experimental Cardiovascular Physiology, Avignon University, Avignon, France
| | | | - Jean-Paul Cristol
- Fondation Charles Mion – AIDER Santé, Grabels, France
- CHRU, Montpellier, France
- PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Claire Maufrais
- UPR4278 Laboratory of Experimental Cardiovascular Physiology, Avignon University, Avignon, France
| | - Philippe Obert
- UPR4278 Laboratory of Experimental Cardiovascular Physiology, Avignon University, Avignon, France
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Penny JD, Hur L, Salerno FR, Wong D, Jan MH, McIntyre CW. Non-invasive intradialytic percutaneous perfusion monitoring: a view to the heart through the skin. FRONTIERS IN NEPHROLOGY 2023; 3:1124130. [PMID: 37675381 PMCID: PMC10479609 DOI: 10.3389/fneph.2023.1124130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 06/14/2023] [Indexed: 09/08/2023]
Abstract
Introduction The life-sustaining treatment of hemodialysis (HD) induces recurrent and cumulative systemic circulatory stress resulting in cardiovascular injury. These recurrent insults compound preexisting cardiovascular sequalae leading to the development of myocardial injury and resulting in extremely high morbidity/mortality. This is largely a consequence of challenged microcirculatory flow within the myocardium (evidenced by detailed imaging-based studies). Currently, monitoring during HD is performed at the macrovascular level. Non-invasive monitoring of organ perfusion would allow the detection and therapeutic amelioration of this pathophysiological response to HD. Non-invasive percutaneous perfusion monitoring of the skin (using photoplethysmography-PPG) has been shown to be predictive of HD-induced myocardial stunning (a consequence of segmental ischemia). In this study, we extended these observations to include a dynamic assessment of skin perfusion during HD compared with directly measured myocardial perfusion during dialysis and cardiac contractile function. Methods We evaluated the intradialytic microcirculatory response in 12 patients receiving conventional HD treatments using continuous percutaneous perfusion monitoring throughout HD. Cardiac echocardiography was performed prior to the initiation of HD, and again at peak-HD stress, to assess the development of regional wall motion abnormalities (RWMAs). Myocardial perfusion imaging was obtained at the same timepoints (pre-HD and peak-HD stress), utilizing intravenous administered contrast and a computerized tomography (CT)-based method. Intradialytic changes in pulse strength (derived from PPG) were compared with the development of HD-induced RWMAs (indicative of myocardial stunning) and changes in myocardial perfusion. Results We found an association between the lowest pulse strength reduction (PPG) and the development of RWMAs (p = 0.03) and also with changes in global myocardial perfusion (CT) (p = 0.05). Ultrafiltration rate (mL/kg/hour) was a significant driver of HD-induced circulatory stress [(associated with the greatest pulse strength reduction (p = 0.01), a reduction in global myocardial perfusion (p = 0.001), and the development of RWMAs (p = 0.03)]. Discussion Percutaneous perfusion monitoring using PPG is a useful method of assessing intradialytic hemodynamic stability and HD-induced circulatory stress. The information generated at the microcirculatory level of the skin is reflective of direct measures of myocardial perfusion and the development of HD-induced myocardial stunning. This approach for the detection and management of HD-induced cardiac injury warrants additional evaluation.
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Affiliation(s)
- Jarrin D. Penny
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada
- Department of Medical Biophysics, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Lisa Hur
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada
- Department of Medical Biophysics, Western University, London, ON, Canada
| | - Fabio R. Salerno
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada
- Department of Medical Biophysics, Western University, London, ON, Canada
| | - Dickson Wong
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada
| | - M. Hussain Jan
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada
| | - Christopher W. McIntyre
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada
- Department of Medical Biophysics, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
- Division of Nephrology, London Health Sciences Centre, London, ON, Canada
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Zhang Z, Wang Y. Management of Cardiovascular Diseases in Chronic Hemodialysis Patients. Rev Cardiovasc Med 2023; 24:185. [PMID: 39077004 PMCID: PMC11266462 DOI: 10.31083/j.rcm2407185] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 02/01/2023] [Accepted: 02/23/2023] [Indexed: 07/31/2024] Open
Abstract
Hemodialysis (HD) is the main treatment modality for patients with end-stage kidney disease. Cardiovascular diseases (CVD) are highly prevalent in HD patients and are the leading cause of death in this population, with the mortality from CVD approximately 20 times higher than that of the general population. Traditional and non-traditional cardiovascular risk factors accelerate progression of CVD and exacerbate the prognosis in HD patients. This review provides a brief overview of the characteristics of CVD in HD patients, and a description of advances in its management.
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Affiliation(s)
- Zhen Zhang
- Department of Nephrology, Zhongshan Hospital, Fudan University, 200032 Shanghai, China
- Shanghai Medical Center for Kidney Disease, Shanghai Municipal Health Commission, 200032 Shanghai, China
- Shanghai Institute of Kidney and Dialysis, 200032 Shanghai, China
- Hemodialysis Quality Control Center of Shanghai, Shanghai Medical Quality Control Management Center, 200032 Shanghai, China
| | - Yaqiong Wang
- Department of Nephrology, Zhongshan Hospital, Fudan University, 200032 Shanghai, China
- Shanghai Medical Center for Kidney Disease, Shanghai Municipal Health Commission, 200032 Shanghai, China
- Shanghai Institute of Kidney and Dialysis, 200032 Shanghai, China
- Hemodialysis Quality Control Center of Shanghai, Shanghai Medical Quality Control Management Center, 200032 Shanghai, China
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Anazodo UC, Wong DY, Théberge J, Dacey M, Gomes J, Penny JD, van Ginkel M, Poirier SE, McIntyre CW. Hemodialysis-Related Acute Brain Injury Demonstrated by Application of Intradialytic Magnetic Resonance Imaging and Spectroscopy. J Am Soc Nephrol 2023; 34:1090-1104. [PMID: 36890644 PMCID: PMC10278857 DOI: 10.1681/asn.0000000000000105] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 02/11/2023] [Indexed: 03/10/2023] Open
Abstract
SIGNIFICANCE STATEMENT Hemodialysis (HD) results in reduced brain blood flow, and HD-related circulatory stress and regional ischemia are associated with brain injury over time. However, studies to date have not provided definitive direct evidence of acute brain injury during a HD treatment session. Using intradialytic magnetic resonance imaging (MRI) and spectroscopy to examine HD-associated changes in brain structure and neurochemistry, the authors found that multiple white (WM) tracts had diffusion imaging changes characteristic of cytotoxic edema, a consequence of ischemic insult and a precursor to fixed structural WM injury. Spectroscopy showed decreases in prefrontal N -acetyl aspartate (NAA) and choline concentrations consistent with energy deficit and perfusion anomaly. This suggests that one HD session can cause brain injury and that studies of interventions that mitigate this treatment's effects on the brain are warranted. BACKGROUND Hemodialysis (HD) treatment-related hemodynamic stress results in recurrent ischemic injury to organs such as the heart and brain. Short-term reduction in brain blood flow and long-term white matter changes have been reported, but the basis of HD-induced brain injury is neither well-recognized nor understood, although progressive cognitive impairment is common. METHODS We used neurocognitive assessments, intradialytic anatomical magnetic resonance imaging, diffusion tensor imaging, and proton magnetic resonance spectroscopy to examine the nature of acute HD-associated brain injury and associated changes in brain structure and neurochemistry relevant to ischemia. Data acquired before HD and during the last 60 minutes of HD (during maximal circulatory stress) were analyzed to assess the acute effects of HD on the brain. RESULTS We studied 17 patients (mean age 63±13 years; 58.8% were male, 76.5% were White, 17.6% were Black, and 5.9% were of Indigenous ethnicity). We found intradialytic changes, including the development of multiple regions of white matter exhibiting increased fractional anisotropy with associated decreases in mean diffusivity and radial diffusivity-characteristic features of cytotoxic edema (with increase in global brain volumes). We also observed decreases in proton magnetic resonance spectroscopy-measured N -acetyl aspartate and choline concentrations during HD, indicative of regional ischemia. CONCLUSIONS This study demonstrates for the first time that significant intradialytic changes in brain tissue volume, diffusion metrics, and brain metabolite concentrations consistent with ischemic injury occur in a single dialysis session. These findings raise the possibility that HD might have long-term neurological consequences. Further study is needed to establish an association between intradialytic magnetic resonance imaging findings of brain injury and cognitive impairment and to understand the chronic effects of HD-induced brain injury. CLINICAL TRIALS INFORMATION NCT03342183 .
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Affiliation(s)
- Udunna C. Anazodo
- Lawson Health Research Institute, London, Ontario, Canada
- Department of Medical Biophysics, Western University, London, Ontario, Canada
| | - Dickson Y. Wong
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jean Théberge
- Lawson Health Research Institute, London, Ontario, Canada
- Department of Medical Biophysics, Western University, London, Ontario, Canada
- Department of Medical Imaging, Western University, London, Ontario, Canada
| | - Madeleine Dacey
- Department of Medical Biophysics, Western University, London, Ontario, Canada
| | - Janice Gomes
- Department of Pathology and Laboratory Medicine, Western University, London, Ontario, Canada
- Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada
| | - Jarrin D. Penny
- Department of Medical Biophysics, Western University, London, Ontario, Canada
- Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada
| | - Michael van Ginkel
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Stefan E. Poirier
- Lawson Health Research Institute, London, Ontario, Canada
- Department of Medical Biophysics, Western University, London, Ontario, Canada
| | - Christopher W. McIntyre
- Lawson Health Research Institute, London, Ontario, Canada
- Department of Medical Biophysics, Western University, London, Ontario, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada
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Gamboa JL, Mambungu CA, Clagett AR, Nian H, Yu C, Ikizler TA, Brown NJ. Bradykinin B 2 receptor blockade and intradialytic hypotension. BMC Nephrol 2023; 24:134. [PMID: 37170244 PMCID: PMC10176680 DOI: 10.1186/s12882-023-03192-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 04/30/2023] [Indexed: 05/13/2023] Open
Abstract
INTRODUCTION Intradialytic hypotension (IDH) is a common clinical complication and is associated with increased morbidity and mortality in patients undergoing maintenance hemodialysis (MHD). The pathogenesis of IDH has been attributed to the rapid reduction of plasma volume during hemodialysis and the inadequate compensatory mechanisms in response to hypovolemia, such as the lack of vasoconstriction. This may be due to the increased production of vasodilators, such as bradykinin. In this study we test the hypothesis that bradykinin B2 receptor blockade prevents intradialytic hypotension. METHODS We performed a post-hoc analysis of a double-blind, placebo-controlled, randomized, 2 × 2 crossover clinical trial comparing the continuous infusion of icatibant, a bradykinin B2 receptor blocker, and placebo during hemodialysis. Icatibant or placebo was infused for 30 min before and during hemodialysis in 11 patients on MHD. RESULTS Seven of the patients had IDH, defined as a reduction of systolic blood pressure equal to or greater than 20 mmHg during hemodialysis. Stratified analysis, based on the presence of IDH, revealed that icatibant prevented the decrease in blood pressure compared to placebo in patients with IDH [blood pressure at average nadir (2.5 h after hemodialysis): Placebo,114.3 ± 8.9 vs. icatibant, 125.6 ± 9.1 mmHg, mean ± S.E.M]. Icatibant did not affect blood pressure in the group of patients without IDH. CONCLUSION Bradykinin B2 receptor blocker may prevent the occurrence of IDH. Further studies should evaluate the hemodynamic effects of icatibant during hemodialysis and the symptomatology associated with IDH.
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Affiliation(s)
- Jorge L Gamboa
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University Medical Center, 2222 Pierce Avenue 561B-PRB, Nashville, TN, 37232-6602, USA.
| | - Cindy A Mambungu
- Veterans Administration Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Adrienne R Clagett
- Veterans Administration Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hui Nian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - T Alp Ikizler
- Veterans Administration Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nancy J Brown
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University Medical Center, 2222 Pierce Avenue 561B-PRB, Nashville, TN, 37232-6602, USA
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O'Lone E, Apple FS, Burton JO, Caskey FJ, Craig JC, de Filippi CR, Forfang D, Hicks KA, Jha V, Mahaffey KW, Mark PB, Rossignol P, Scholes-Robertson N, Jaure A, Viecelli AK, Wang AY, Wheeler DC, White D, Winkelmayer WC, Herzog CA. Defining Myocardial Infarction in trials of people receiving hemodialysis: consensus report from the SONG-HD MI Expert Working group. Kidney Int 2023; 103:1028-1037. [PMID: 37023851 DOI: 10.1016/j.kint.2023.02.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/22/2023] [Accepted: 02/15/2023] [Indexed: 04/08/2023]
Abstract
Cardiovascular disease is the leading cause of death in patients receiving hemodialysis. Currently there is no standardized definition of myocardial infarction (MI) for patients receiving hemodialysis. Through an international consensus process MI was established as the core CVD measure for this population in clinical trials. The Standardised Outcomes in Nephrology Group - Hemodialysis (SONG-HD) initiative convened a multidisciplinary, international working group to address the definition of MI in this population.Based on current evidence, the working group recommends using the 4th Universal Definition of MI with specific caveats with regard to the interpretation of "ischemic symptoms" and performing a baseline 12-lead electrocardiogram to facilitate interpretation of acute changes on subsequent tracings. The working group does not recommend obtaining baseline cardiac troponin values, though does recommend obtaining serial cardiac biomarkers in settings where ischemia is suspected. Application of an evidence-based uniform definition should increase the reliability and accuracy of trial results.
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Affiliation(s)
- E O'Lone
- The University of Sydney, Camperdown, Sydney, Australia.
| | - F S Apple
- Departments of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota
| | - J O Burton
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital Leicester, Leicester, UK
| | - F J Caskey
- Population Health Sciences, University of Bristol, Southmead Hospital, Bristol, UK
| | - J C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - C R de Filippi
- Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - D Forfang
- The National Forum of ESRD Networks, Kidney Patient Advisory Council (KPAC) WI USA
| | - K A Hicks
- Division of Cardiology and Nephrology, Office of Cardiology, Hematology, Endocrinology, and Nephrology, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - V Jha
- George Institute of Global Health, UNSW, New Delhi, India; School of Public Health, Imperial College, London, UK; Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - K W Mahaffey
- The Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - P B Mark
- University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - P Rossignol
- Université de Lorraine, Centre d'Investigation Clinique Plurithématique 1433 -INSERM- CHRU de Nancy, Inserm U1116 & FCRIN INI-CRCT (Cardiovascular and RenalClinical Trialists), Vandoeuvre-les-Nancy, France; Medical specialties and nephrology -hemodialysis departments, Princess Grace Hospital, and Monaco Private Hemodialysis Centre, Monaco, Monaco
| | - N Scholes-Robertson
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - A Jaure
- The University of Sydney, Camperdown, Sydney, Australia; Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - A K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - A Y Wang
- Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - D C Wheeler
- University College London, London, United Kingdom
| | - D White
- American Association of Kidney Patients, Tampa, Florida
| | - W C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - C A Herzog
- Chronic Disease Research Group, Hennepin Healthcare Research Institute,Minneapolis, Minnesota; Division of Cardiology, Department of Medicine, Hennepin Healthcare and University of Minnesota, Minneapolis, Minnesota
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Yildiz AB, Vehbi S, Covic A, Burlacu A, Covic A, Kanbay M. An update review on hemodynamic instability in renal replacement therapy patients. Int Urol Nephrol 2023; 55:929-942. [PMID: 36308664 DOI: 10.1007/s11255-022-03389-w] [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: 05/24/2022] [Accepted: 10/15/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hemodynamic instability in patients undergoing kidney replacement therapy (KRT) is one of the most common and essential factors influencing mortality, morbidity, and the quality of life in this patient population. METHOD Decreased cardiac preload, reduced systemic vascular resistance, redistribution of fluids, fluid overload, inflammatory factors, and changes in plasma osmolality have all been implicated in the pathophysiology of hemodynamic instability associated with KRT. RESULT A cascade of these detrimental mechanisms may ultimately cause intra-dialytic hypotension, reduced tissue perfusion, and impaired kidney rehabilitation. Multiple parameters, including dialysate composition, temperature, posture during dialysis sessions, physical activity, fluid administrations, dialysis timing, and specific pharmacologic agents, have been studied as possible management modalities. Nevertheless, a clear consensus is not reached. CONCLUSION This review includes a thorough investigation of the literature on hemodynamic instability in KRT patients, providing insight on interventions that may potentially minimize factors leading to hemodynamic instability.
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Affiliation(s)
- Abdullah B Yildiz
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Sezan Vehbi
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Andreea Covic
- Department of Nephrology, Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Alexandru Burlacu
- Department of Nephrology, Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Adrian Covic
- Department of Nephrology, Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, 34010, Istanbul, Turkey.
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Søndergaard H. Time to go home. J Ren Care 2023; 49:4-5. [PMID: 36788433 DOI: 10.1111/jorc.12456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 01/02/2023] [Indexed: 02/16/2023]
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Iwashima Y, Fukushima H, Horio T, Rai T, Ishimitsu T. Blood pressure, arterial waveform, and arterial stiffness during hemodialysis and their clinical implications in intradialytic hypotension. Hypertens Res 2023; 46:697-707. [PMID: 36522423 DOI: 10.1038/s41440-022-01126-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/28/2022] [Accepted: 11/05/2022] [Indexed: 12/23/2022]
Abstract
This study included 152 hemodialysis patients (mean age, 69 years; 34.2% female) and investigated serial changes in blood pressure (BP) and arterial stiffness indices during hemodialysis using an oscillometric device, SphygmoCor XCEL, and examined whether assessment of the arterial waveform has clinical implications for the management of intradialytic hypotension (IDH). Measurement was performed every 30 min during hemodialysis, and the threshold defining IDH was systolic BP (SBP) decrease ≥40 mmHg or a requirement for antihypotensive medication in all patients and ≥ the 75th percentile of maximum SBP decrease during hemodialysis (≥34 mmHg) in the subgroup without antihypotensive medication (n = 98). In all patients, a 1-standard deviation (SD) increase in the baseline subendocardial viability ratio (SEVR), an index of myocardial perfusion, was an independent predictor of IDH (odds ratio [OR] 0.43, p < 0.001). In the subgroup analysis, a serial change in SBP and all arterial waveform indices, including the augmentation index, augmented pressure (AP), and SEVR, during hemodialysis were greater for IDH than for non-IDH patients (all p < 0.01 by 2-way repeated-measures ANOVA), with the exception of heart rate (p = 0.40) and diastolic pressure time index (p = 0.21). Diabetes (OR 4.08), a 1-SD increase in ultrafiltration rate (OR 2.07), fractional shortening (OR 0.45), baseline SEVR (OR 0.36) and the first 1-h percent change in AP (OR 0.52) were independent predictors of IDH (all p < 0.05). In conclusion, impaired myocardial perfusion and increased arterial stiffness, particularly poor arteriolar responsiveness to acute dialysis-related changes, are associated with IDH, and predialysis SEVR evaluation can complement screening for IDH.
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Affiliation(s)
- Yoshio Iwashima
- Department of Nephrology and Hypertension, Dokkyo Medical University, Tochigi, Japan. .,Department of Internal Medicine, Kansai Medical University Kori Hospital, Oaka, Japan.
| | | | - Takeshi Horio
- Department of Cardiovascular Medicine, Ishikiriseiki Hospital, Osaka, Japan
| | - Tatemitsu Rai
- Department of Nephrology and Hypertension, Dokkyo Medical University, Tochigi, Japan
| | - Toshihiko Ishimitsu
- Department of Nephrology and Hypertension, Dokkyo Medical University, Tochigi, Japan
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Chan RJ, Helmeczi W, Canney M, Clark EG. Management of Intermittent Hemodialysis in the Critically Ill Patient. Clin J Am Soc Nephrol 2023; 18:245-255. [PMID: 35840348 PMCID: PMC10103228 DOI: 10.2215/cjn.04000422] [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: 11/23/2022]
Abstract
Intermittent hemodialysis remains a cornerstone of extracorporeal KRT in the intensive care unit, either as a first-line therapy for AKI or a second-line therapy when patients transition from a continuous or prolonged intermittent therapy. Intermittent hemodialysis is usually provided 3 days per week in this setting on the basis that no clinical benefits have been demonstrated with more frequent hemodialysis. This should not detract from the importance of continually assessing and refining the hemodialysis prescription (including the need for extra treatments) according to dynamic changes in extracellular volume and other parameters, and ensuring that an adequate dose of hemodialysis is being delivered to the patient. Compared with other KRT modalities, the cardinal challenge encountered during intermittent hemodialysis is hemodynamic instability. This phenomenon occurs when reductions in intravascular volume, as a consequence of ultrafiltration and/or osmotic shifts, outpace compensatory plasma refilling from the extravascular space. Myocardial stunning, triggered by intermittent hemodialysis, and independent of ultrafiltration, may also contribute. The hemodynamic effect of intermittent hemodialysis is likely magnified in patients who are critically ill due to an inability to mount sufficient compensatory physiologic responses in the context of multiorgan dysfunction. Of the many interventions that have undergone testing to mitigate hemodynamic instability related to KRT, the best evidence exists for cooling the dialysate and raising the dialysate sodium concentration. Unfortunately, the evidence supporting routine use of these and other interventions is weak owing to poor study quality and limited sample sizes. Intermittent hemodialysis will continue to be an important and commonly used KRT modality for AKI in patients with critical illness, especially in jurisdictions where resources are limited. There is an urgent need to harmonize the definition of hemodynamic instability related to KRT in clinical trials and robustly test strategies to combat it in this vulnerable patient population.
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Affiliation(s)
- Ryan J. Chan
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Wryan Helmeczi
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mark Canney
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Edward G. Clark
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Elsayed N, Vasudevan RS, Zarrintan S, Barleben A, Kashyap VS, Malas MB. TransCarotid Artery Revascularization Can Be Safely Performed in Patients Undergoing Dialysis. Ann Vasc Surg 2023; 92:57-64. [PMID: 36690251 DOI: 10.1016/j.avsg.2023.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/27/2022] [Accepted: 01/05/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND TransCarotid Artery Revascularization (TCAR) has been effectively performed to prevent stroke in patients with carotid artery stenosis (CS). Prior studies established that TCAR can be safely performed in high-risk patients such as octogenarians, patients with prior carotid endarterectomy (CEA), contralateral occlusion, and heavily calcified lesions. Hemodialysis patients are at an increased risk of exhibiting cardiovascular complications. This study aims to investigate how dialysis may affect TCAR outcomes. METHODS The Vascular Quality Initiative (VQI) dataset was queried for patients undergoing TCAR from November 2016 to November 2021. Patients were divided into dialysis and nondialysis groups. The primary outcome was the composite endpoint of in-hospital stroke, death, or myocardial infarction (MI). Secondary outcomes were in-hospital stroke, stroke, or transient ischemic attack (TIA), death, prolonged length of stay (more than 1 day) (PLOS), MI, and stroke or death. Multivariable logistic regression analysis was used to assess in-hospital outcomes. Kaplan-Meier survival and log-rank test were used to assess 1-year survival. RESULTS A total of 22,619 patients underwent TCAR during the study period. Of these, 327 patients were undergoing dialysis. On univariable analysis, dialysis patients were associated with a higher risk of mortality compared to nondialysis patients (1.2% vs. 0.6%, P = 0.030). However, after adjusting for potential confounders, this difference did not persist (odd ratio [OR]: 1.99, 95% confidence interval [CI] (0.8-4.9), P = 0.136). Dialysis patients were more likely to experience PLOS (OR: 1.6, 95% CI (1.2-2), P < 0.001). There was no difference between dialysis and nondialysis patients in the risk of stroke or death, stroke, stroke or TIA, MI, and stroke or death, or MI on univariable and multivariable analyses. At 1 year, the overall survival for dialysis versus nondialysis patients was 81.5% vs. 95.5%, P < 0.001. CONCLUSIONS To our knowledge, this is the first study to date of dialysis patients who have undergone TCAR. We have shown that there was no difference in the risk of stroke, death, and MI between dialysis and nondialysis patients. Therefore, TCAR can be safely offered to patients undergoing dialysis. Future studies with larger number of patients are warranted to confirm these results.
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Affiliation(s)
- Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Rajiv S Vasudevan
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Sina Zarrintan
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Andrew Barleben
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Vikram S Kashyap
- Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA.
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43
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Frequency and type of arrhythmia in Holter electrocardiogram in patients undergoing hemodialysis. JOURNAL OF SURGERY AND MEDICINE 2023. [DOI: 10.28982/josam.7584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Background/Aim: It is known that approximately 40% of chronic hemodialysis patients die due to cardiac arrhythmia and cardiovascular reasons. Determining whether the hemodialysis procedure poses a risk for arrhythmia is important in terms of prognostic follow-up of the patients. Therefore, we aimed to determine the underlying arrhythmia frequency and types with 24-hour Holter electrocardiogram (ECG) in patients receiving hemodialysis with normal baseline electrocardiography between the hemodialysis periods.
Methods: Between January 2018 and January 2022, 91 consecutive patients who received hemodialysis for chronic renal failure (CRF) and applied to the cardiology outpatient clinic with complaints of palpitation and sinus rhythm on ECG and evaluated with 24-hour rhythm Holter ECG were included in the study. Our study was designed as a retrospective cohort study.
Results: The mean age of the patient population was 65.78 (11.92) years, the mean systolic blood pressure was 143.71 (24.88) mmHg, and the mean heart rate was 83.43 (15.85) beats/min. Hypertension (HT) (n=44, 48%) and coronary artery disease (n=34, 37%) were the most common comorbid diseases. The most common arrhythmias detected on Holter ECG were ventricular extrasystole (VES) (n=18, 19.8%) and paroxysmal AF (n=8, 8.8%). Non-sustained ventricular tachycardia was detected in two patients.
Conclusion: Detecting arrhythmia in the interdialytic periods in patients receiving hemodialysis due to CRF is important for follow-up and treatment. Even if the baseline ECG is normal in hemodialysis patients with CRF, the frequency of the underlying arrhythmia that needs to be treated is high.
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Oxygen Extraction and Mortality in Patients Undergoing Chronic Haemodialysis Treatment: A Multicentre Study. J Clin Med 2022; 12:jcm12010138. [PMID: 36614939 PMCID: PMC9821439 DOI: 10.3390/jcm12010138] [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: 11/21/2022] [Revised: 12/17/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
Patients on haemodialysis (HD) suffer a high mortality rate linked to developing subclinical hypoxic parenchymal stress during HD sessions. The oxygen extraction ratio (OER), an estimate of the oxygen claimed by peripheral tissues, might represent a new prognostic factor in HD patients. This study evaluated whether the intradialytic change in OER (ΔOER) identified patients with higher mortality risks. We enrolled chronic HD patients with permanent central venous catheters with available central venous oxygen saturation (ScvO2) measurements; the arterial oxygen saturation was measured with peripheral oximeters (SpO2). We measured OER before and after HD at enrolment; deaths were recorded during two-years of follow-up. In 101 patients (age: 72.9 ± 13.6 years, HD vintage: 9.6 ± 16.6 years), 44 deaths were recorded during 11.6 ± 7.5 months of follow-up. Patients were divided into two groups according to a 40% ΔOER threshold (ΔOER < 40%, n = 56; ΔOER ≥ 40%, n = 45). The ΔOER ≥ 40% group showed a higher incidence of death (60% vs. 30%; p = 0.005). The survival curve (log-rank-test: p = 0.0001) and multivariate analysis (p = 0.0002) confirmed a ΔOER ≥ 40% as a mortality risk factor. This study showed the intradialytic ΔOER ≥ 40% was a mortality risk factor able to highlight critical hypoxic damage. Using a ΔOER ≥ 40% could be clinically applicable to characterise the most fragile patients.
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Lin X, Wu G, Gao B, Wang S, Huang J. Bibliometric and visual analysis of coronary microvascular dysfunction. Front Cardiovasc Med 2022; 9:1021346. [PMID: 36457808 PMCID: PMC9705352 DOI: 10.3389/fcvm.2022.1021346] [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: 08/17/2022] [Accepted: 10/31/2022] [Indexed: 11/05/2023] Open
Abstract
Background Coronary microvascular dysfunction (CMD) may play an important role in various cardiovascular diseases, including HFpEF and both obstructive and non-obstructive coronary artery disease (CAD). To date, there has been no bibliometric analysis to summarize this field. Here, we aim to conduct a bibliometric analysis of CMD to determine the current status and frontiers in this field. Materials and methods Publications about CMD were taken from the Web of Science Core Collection database (WOSCC). WOSCC's literature analysis wire, the VOSviewer 1.6.16, and CiteSpace 5.1.3 were used to conduct the analysis. Results A total of 785 publications containing 206 reviews and 579 articles are included in the sample. The leading authors are Iacopo Olivotto, Paolo G. Camici, and Carl J. Pepine. The most productive institutions are the University of Florence, Cedars Sinai Medical Center, and Harvard University. The most productive countries are the USA, Italy, and England. There are a total of 237 journals that contribute to this field, and the leading journals in our study were the International Journal of Cardiology, the European Heart Journal and the JACC. From 2012 to 2021, the top three most-cited articles focused on the association between HFpEF and CMD. The important keywords are heart failure, hypertrophic cardiomyopathy, chest pain, women, coronary flow reserve (CFR), endothelial dysfunction and prognostic value. "Positron emission tomography" shows the strongest burst strength, followed by "blow flow" and "artery." The keywords that started to burst from 2015 are particularly emphasized, including "heart failure," "coronary flow reserve," and "management." Conclusion Studies about CMD are relatively limited, and the largest contribution comes from the USA, Italy and England. More studies are needed, and publications from other countries should be enhanced. The main research hotspots in the CMD field include CMD in patients with HFpEF, sex differences, the new methods of diagnosis for CMD, and the effective treatment of CMD. Attention should be given to CMD in patients with HFpEF, and untangling the association between CMD and HFpEF could be helpful in the development of physiology-stratified treatment for patients with CMD and HFpEF.
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Affiliation(s)
- Xiaoxiao Lin
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Guomin Wu
- Department of Cardiology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Beibei Gao
- Department of Cardiology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shuai Wang
- Department of Translation Medicine Center, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jinyu Huang
- Department of Cardiology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
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46
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Forsberg U, Jonsson P, Stegmayr B. Microemboli induced by air bubbles may be deposited in organs as a consequence of contamination during medical care. Clin Kidney J 2022; 16:159-166. [PMID: 36726427 PMCID: PMC9871849 DOI: 10.1093/ckj/sfac217] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Background Larger volumes of accidental air infused during medical care may end up as emboli while microbubbles of air are supposed to be absorbed and cause no harm. The aim of this autopsy study was to investigate if microbubbles of air accidently entering the bloodline may be detected as microemboli (ME) in tissue such as lungs, brain and heart. If so, do differences in prevalence exist between haemodialysis (HD) and amyotrophic lateral sclerosis (ALS) patients. Methods Included were data from 44 patients treated by medical healthcare before death. Twenty-five cases had been treated with chronic HD and 19 cases died from ALS. Since air in the bloodline activates coagulation, ME could appear. To discriminate between microbubbles caused by artificial contamination during autopsy versus microbubbles deposited in vivo, tissues were stained with a polyclonal fluorescent antibody against fibrinogen, fibrin and fragments E and D. Fluorescence staining was used to visualize ME counted within 25 microscopic fields (600×) of a tissue preparation. One tissue preparation was used if available from the lung, heart and frontal lobe of the brain and in five cases also the cerebellum. Results Microbubbles can be verified at autopsy as ME in the lung, heart and brain in tissue from patients exposed to more extensive medical care. There were significantly more ME in the lungs versus the heart or brain. Women had fewer ME than men. The HD group had a higher median of ME per section than the ALS group (lung: 6 versus 3, P = .007; heart: 2.5 versus 1, P = .013; brain: 7.5 versus 2, P = .001) and had more sections with ME findings than the ALS group (P = .002). A correlation existed between the time on HD (months) and ME in the lungs. Conclusions More ME were present in HD patients compared with those who suffered from ALS. Minimizing air contamination from syringes, infusions and bloodlines will decrease ME and subsequent tissue injury.
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Affiliation(s)
| | - Per Jonsson
- Unit of Medicine, Umeå University, Umeå, Sweden
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47
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Clemmer JS, Shafi T, Obi Y. Physiological Mechanisms of Hypertension and Cardiovascular Disease in End-Stage Kidney Disease. Curr Hypertens Rep 2022; 24:413-424. [PMID: 35708820 PMCID: PMC10041674 DOI: 10.1007/s11906-022-01203-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW In this article, we summarize recent advances in understanding hypertension and cardiovascular disease in patients with end-stage kidney disease. RECENT FINDINGS Factors such as anemia, valvular and vascular calcification, vasoconstrictors, uremic toxins, hypoglycemia, carbamylated proteins, oxidative stress, and inflammation have all been associated with the progression of cardiovascular disease in end-stage kidney disease but the causality of these mechanisms has not been proven. The high risk of cardiovascular mortality has not improved as in the general population despite many advancements in cardiovascular care over the last two decades. Mechanisms that increase hypertension risk in these patients are centered on the control of extracellular fluid volume; however, over-correction of volume with dialysis can increase risks of intradialytic hypotension and death in these patients. This review presents both recent and classic work that increases our understanding of hypertension and cardiovascular disease in end-stage kidney disease.
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Affiliation(s)
- John S Clemmer
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS, USA
| | - Tariq Shafi
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS, USA.,Division of Nephrology, University of Mississippi Medical Center, 2500 North State Street, Suite L-504, Jackson, MS, 39216, USA
| | - Yoshitsugu Obi
- Division of Nephrology, University of Mississippi Medical Center, 2500 North State Street, Suite L-504, Jackson, MS, 39216, USA.
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High Inferior Vena Cava Diameter with High Left Ventricular End Systolic Diameter as a Risk Factor for Major Adverse Cardiovascular Events, Cardiovascular and Overall Mortality among Chronic Hemodialysis Patients. J Clin Med 2022; 11:jcm11185485. [PMID: 36143131 PMCID: PMC9503705 DOI: 10.3390/jcm11185485] [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: 08/11/2022] [Revised: 09/08/2022] [Accepted: 09/15/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Little is known about the association of inferior vena cava diameter (IVCD) and left ventricular end-systolic diameter (LVESD) with mortality in patients undergoing hemodialysis (HD). Methods: The single medical center observational cohort study enrolled 241 adult chronic HD patients from 1 October 2018 to 31 December 2018. Echocardiography results of IVCD and LVESD prior to dialysis were retrieved and patients were divided into high IVCD and low IVCD groups. Patients who received HD via a tunneled cuffed catheter were excluded. Study outcomes included all-cause mortality, cardiovascular mortality, and major adverse cardiovascular events (MACE). Subgroup analyses of HD patients with high and low LVESD were also performed. Results: The incidence of all-cause mortality, cardiovascular mortality, and MACE were higher in chronic HD patients with high IVCD (p < 0.01). High IVCD patients had significantly greater all-cause mortality, cardiovascular mortality, and MACE (log-rank test; p < 0.05). High IVCD patients are also associated with an increased risk of all-cause mortality and MACE relative to low IVCD patients (aHRs, 2.88 and 3.42; 95% CIs, 1.06−7.86 and 1.73−6.77, respectively; all p < 0.05). In the subgroup analysis of patients with high or low LVESD, the high IVCD remained a significant risk factor for all-cause mortality and MACE, and the HR is especially high in the high LVESD group. Conclusions: Dilated IVCD is a risk factor for all-cause mortality and MACE in chronic HD patients. In addition, these patients with high LVESD also have a significantly higher HR of all-cause mortality and MACE.
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Arroyo E, Umukoro PE, Burney HN, Li Y, Li X, Lane KA, Sher SJ, Lu T, Moe SM, Moorthi R, Coggan AR, McGregor G, Hiemstra TF, Zehnder D, Lim K. Initiation of Dialysis Is Associated With Impaired Cardiovascular Functional Capacity. J Am Heart Assoc 2022; 11:e025656. [PMID: 35861826 PMCID: PMC9707847 DOI: 10.1161/jaha.122.025656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/02/2022] [Indexed: 11/16/2022]
Abstract
Background The transition to dialysis period carries a substantial increased cardiovascular risk in patients with chronic kidney disease. Despite this, alterations in cardiovascular functional capacity during this transition are largely unknown. The present study therefore sought to assess ventilatory exercise response measures in patients within 1 year of initiating dialysis. Methods and Results We conducted a cross-sectional study of 241 patients with chronic kidney disease stage 5 from the CAPER (Cardiopulmonary Exercise Testing in Renal Failure) study and from the intradialytic low-frequency electrical muscle stimulation pilot randomized controlled trial cohorts. Patients underwent cardiopulmonary exercise testing and echocardiography. Of the 241 patients (age, 48.9 [15.0] years; 154 [63.9%] men), 42 were predialytic (mean estimated glomerular filtration rate, 14 mL·min-1·1.73 m-2), 54 had a dialysis vintage ≤12 months, and 145 had a dialysis vintage >12 months. Dialysis vintage ≤12 months exhibited a significantly impaired cardiovascular functional capacity, as assessed by oxygen uptake at peak exercise (18.7 [5.8] mL·min-1·kg-1) compared with predialysis (22.7 [5.2] mL·min-1·kg-1; P<0.001). Dialysis vintage ≤12 months also exhibited reduced peak workload, impaired peak heart rate, reduced circulatory power, and increased left ventricular mass index (P<0.05 for all) compared with predialysis. After excluding those with prior kidney transplant, dialysis vintage >12 months exhibited a lower oxygen uptake at peak exercise (17.0 [4.9] mL·min-1·kg-1) compared with dialysis vintage ≤12 months (18.9 [5.9] mL·min-1·kg-1; P=0.033). Conclusions Initiating dialysis is associated with a significant impairment in oxygen uptake at peak exercise and overall decrements in ventilatory and hemodynamic exercise responses that predispose patients to functional dependence. The magnitude of these changes is comparable to the differences between low-risk New York Heart Association class I and higher-risk New York Heart Association class II to IV heart failure.
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Affiliation(s)
- Eliott Arroyo
- Division of Nephrology and HypertensionDepartment of MedicineIndiana University School of MedicineIndianapolisIN
| | - Peter E. Umukoro
- Division of Nephrology and HypertensionDepartment of MedicineIndiana University School of MedicineIndianapolisIN
- Department of NephrologyHendricks Regional HealthDanvilleIN
| | - Heather N. Burney
- Department of Biostatistics and Health Data ScienceIndiana University School of MedicineIndianapolisIN
| | - Yang Li
- Department of Biostatistics and Health Data ScienceIndiana University School of MedicineIndianapolisIN
| | - Xiaochun Li
- Department of Biostatistics and Health Data ScienceIndiana University School of MedicineIndianapolisIN
| | - Kathleen A. Lane
- Department of Biostatistics and Health Data ScienceIndiana University School of MedicineIndianapolisIN
| | - S. Jawad Sher
- Division of Nephrology and HypertensionDepartment of MedicineIndiana University School of MedicineIndianapolisIN
| | - Tzong‐shi Lu
- Renal DivisionDepartment of MedicineBrigham and Women’s Hospital and Harvard Medical SchoolBostonMA
| | - Sharon M. Moe
- Division of Nephrology and HypertensionDepartment of MedicineIndiana University School of MedicineIndianapolisIN
| | - Ranjani Moorthi
- Division of Nephrology and HypertensionDepartment of MedicineIndiana University School of MedicineIndianapolisIN
| | - Andrew R. Coggan
- Department of KinesiologyIndiana University–Purdue University IndianapolisIndianapolisIN
| | - Gordon McGregor
- Department of NephrologyUniversity Hospital Coventry and Warwickshire National Health Service TrustCoventryUnited Kingdom
- Department of CardiologyUniversity Hospital Coventry and Warwickshire National Health Service TrustCoventryUnited Kingdom
- Centre for Sport, Exercise, and Life SciencesCoventry UniversityCoventryUnited Kingdom
- Warwick Clinical Trials UnitWarwick Medical SchoolUniversity of WarwickCoventryUnited Kingdom
| | - Thomas F. Hiemstra
- Cambridge Clinical Trials UnitCambridge University Hospitals National Health Service Foundation TrustCambridgeUnited Kingdom
- School of Clinical MedicineUniversity of CambridgeCambridgeUnited Kingdom
| | - Daniel Zehnder
- Department of NephrologyNorth Cumbria University Hospital National Health Service TrustCarlisleUnited Kingdom
- Department of Acute MedicineNorth Cumbria University Hospital National Health Service TrustCarlisleUnited Kingdom
| | - Kenneth Lim
- Division of Nephrology and HypertensionDepartment of MedicineIndiana University School of MedicineIndianapolisIN
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50
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Causland FRM, Ravi KS, Curtis KA, Kibbelaar ZA, Short SAP, Singh AT, Correa S, Waikar SS. A randomized controlled trial of two dialysate sodium concentrations in hospitalized hemodialysis patients. Nephrol Dial Transplant 2022; 37:1340-1347. [PMID: 34792161 PMCID: PMC9217525 DOI: 10.1093/ndt/gfab329] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Several large dialysis organizations have lowered the dialysate sodium concentration (DNa) in an effort to ameliorate hypervolemia. The implications of lower DNa on intra-dialytic hypotension (IDH) during hospitalizations of hemodialysis (HD) patients is unclear. METHODS In this double-blind, single center, randomized controlled trial (RCT), hospitalized maintenance HD patients were randomized to receive higher (142 mmol/L) or lower (138 mmol/L) DNa for up to six sessions. Blood pressure (BP) was measured in a standardized fashion pre-HD, post-HD and every 15 min during HD. The endpoints were: (i) the average decline in systolic BP (pre-HD minus lowest intra-HD, primary endpoint) and (ii) the proportion of total sessions complicated by IDH (drop of ≥20 mmHg from the pre-HD systolic BP, secondary endpoint). RESULTS A total of 139 patients completed the trial, contributing 311 study visits. There were no significant differences in the average systolic blood pressure (SBP) decline between the higher and lower DNa groups (23 ± 16 versus 26 ± 16 mmHg; P = 0.57). The proportion of total sessions complicated by IDH was similar in the higher DNa group, compared with the lower DNa group [54% versus 59%; odds ratio 0.72; 95% confidence interval (95% CI) 0.36-1.44; P = 0.35]. In post hoc analyses adjusting for imbalances in baseline characteristics, higher DNa was associated with 8 mmHg (95% CI 2-13 mmHg) less decline in SBP, compared with lower DNa. Patient symptoms and adverse events were similar between the groups. CONCLUSIONS In this RCT for hospitalized maintenance of HD patients, we found no difference in the absolute SBP decline between those who received higher versus lower DNa in intention-to-treat analyses. Post hoc adjusted analyses suggested a lower risk of IDH with higher DNa; thus, larger, multi-center studies to confirm these findings are warranted.
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Affiliation(s)
- Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Katherine Scovner Ravi
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Katherine A Curtis
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Zoé A Kibbelaar
- Renal Section, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Samuel A P Short
- Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Anika T Singh
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Simon Correa
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sushrut S Waikar
- Renal Section, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
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