Intradialytic hypotension: is timing everything?

Incremental Hemodialysis: Review of Clinical Trials Focused on Patients Undergoing Once-Weekly Hemodialysis

Background/objectives: The implementation of appropriate hemodialysis treatment in the transition from end-stage kidney disease to reduced frequency schedules represents a major challenge. The aim of our work is to report only treatment protocols that used once-weekly hemodialysis. Methods: The benefits and risks of 1WHD were explored in this systematic review. A search of MEDLINE, Scopus, and the Cochrane Central Register was conducted to identify publications relating to once-weekly hemodialysis trials performed between June 1981 and December 2024 and assess clinical impact, duration, safety, and mortality. Items, including age, causes of chronic kidney disease (CKD), creatinine levels, Blood Urea Nitrogen and GFR values, diuresis, nutritional supplementation, drop-out, survival, clinical benefit or drawbacks, and data from eventual control groups relating to higher frequency weekly HD sessions were included. Outcome at the end of a 1WHD regimen was represented by death or transition to twice/thrice-weekly HD rhythms. Results: A total of 1238 articles focused on IHD were included in the review, and 1226 trials were excluded as they referred either to twice-weekly hemodialysis (2WHD) schedules or failed to meet eligibility criteria, whilst another two were excluded based on incomplete outcome or patient recruitment issues. A total of eight articles comprising 254 patients undergoing 1WHD schedules were ultimately identified and evaluated. Only three studies focused on a comparison with a 1WHD schedule, whilst 107 referred to thrice-weekly HD (3WHD) and 15 2WHD). This choice demonstrated the possibility of slowing down the progression of CKD in the patients studied. Daily amino acid supplementation also proved to be beneficial. However, the milestone on which the 1WHD protocol is based is a low-protein diet. Conclusions: 1WHD has been shown to be safe and may result in improved clinical outcomes, particularly in appropriately selected patients. Large-scale randomized controlled trials should be carried out to confirm these potential advantages. However, the standard recruitment techniques applied tended to prevent suitably selected patients from transitioning into less frequent and potentially long-lasting 1WHD schedules.

External validation of the prediction model of intradialytic hypotension: a multicenter prospective cohort study

OBJECTIVE

Intradialytic hypotension (IDH) is a common and serious complication in patients with Maintenance Hemodialysis (MHD). The purpose of this study is to externally verify three IDH risk prediction models recently developed by Ma et al. and recalibrate, update and present the optimal model to improve the accuracy and applicability of the model in clinical environment.

METHODS

A multicenter prospective cohort study of patients from 11 hemodialysis centers in Sichuan Province, China, was conducted using convenience sampling from March 2022 to July 2022, with a follow-up period of 1 month. Model performance was assessed by: (1) Discrimination: Evaluated through the computation of the Area Under Curve (AUC) and its corresponding 95% confidence intervals. (2) Calibration: scrutinized through visual inspection of the calibration plot and utilization of the Brier score. (3) The incremental value of risk prediction and the utility of updating the model were gauged using NRI (Net Reclassification Improvement) and IDI (Integrated Discrimination Improvement). Decision Curve Analysis (DCA) was employed to evaluate the clinical benefit of updating the model.

RESULTS

The final cohort comprised 2235 individuals undergoing maintenance hemodialysis, exhibiting a 14.6% occurrence rate of IDH. The externally validated Area Under the Curve (AUC) values for the three original prediction models were 0.746 (95% CI: 0.718 to 0.775), 0.709 (95% CI: 0.679 to 0.739), and 0.735 (95% CI: 0.706 to 0.764) respectively. Conversely, the AUC value for the recalibrated and updated columnar plot model reached 0.817 (95% CI: 0.791 to 0.842), accompanied by a Brier score of 0.081. Furthermore, Decision Curve Analysis (DCA) exhibited a net benefit within the threshold probability range of 15.2% to 87.1%.

CONCLUSION

Externally validated, recalibrated, updated, and presented IDH prediction models may serve as a valuable instrument for evaluating IDH risk in clinical practice. Furthermore, they hold the potential to guide clinical providers in discerning individuals at risk and facilitating judicious clinical intervention decisions.