How should we manage adverse intradialytic blood pressure changes?

Impact of barometric pressure on blood pressure during dialysis: Introducing intradialytic time-averaged cumulative systolic blood pressure (TACsBP-inD) as a new metric

BACKGROUND

Blood pressure is a crucial risk factor for hemodialysis patients, but the specific impact of weather factors, particularly barometric pressure, on blood pressure remains unclear. This study aims to examine the relationship between barometric pressure and blood pressure in hemodialysis patients.

METHODS

We conducted a single-center, retrospective study involving 122 hemodialysis patients in Japan, covering the period from August 2018 to October 2022. In addition to standard blood pressure indices, for the purpose of a more accurate assessment, we introduced the intradialytic time-averaged cumulative systolic blood pressure (TACsBP-inD). Multilevel mixed-effects linear regression models with random intercepts for each patient and spline analyses were used to evaluate the association between barometric pressure and blood pressure.

RESULTS

Our analysis demonstrated a positive correlation between barometric pressure and various intradialytic blood pressure indices, including TACsBP-inD, in both univariate and multivariate models. Spline analyses revealed a U-shaped relationship between barometric pressure and TACsBP-inD. Furthermore, categorized barometric pressure showed significantly positive coefficients for TACsBP-inD at both lower and higher pressure ranges, supporting the U-shaped trend. Subgroup analyses revealed that this positive association was not observed at lower pressures among males, obese individuals, and patients with diabetes, cardiovascular disease, and smoking habits, suggesting that blood pressure responses vary depending on patient profiles.

CONCLUSIONS

These findings emphasize the significant impact of barometric pressure on intradialytic blood pressure, suggesting that atmospheric conditions could be an important consideration in blood pressure management for hemodialysis patients.

Intradialytic Hypotension Pathophysiology and Therapy Update: Review and Update

BackgroundIntradialytic hypotension (IDH) is the most prevalent complication during hemodialysis (HD) sessions, affecting 10% to 12% of patients. It is linked with temporary ischemic stress in vital organs, increasing patient mortality. Various definitions of IDH have been proposed, and a strong correlation has been found between patient outcomes and the absolute lowest systolic blood pressure. The most probable underlying pathophysiology of IDH involves a reduced effective blood volume and decreased plasma tonicity. Optimizing the dialysis prescription and interventions during and after the dialysis session is sometimes effective for reducing IDH risk.Aim and MethodThis review discusses the pathophysiology, prevention, and therapy of IDH updates. To achieve this aim, Scopus, EMBASE, PubMed, Google, and Google Scholar were searched for articles published in the last two decades using phrases and keywords.ConclusionIntradialytic pathophysiology is ambiguous and unclear. The evidence for the effectiveness of the known therapies and maneuvers is limited. Ideally, IDH prevention should be the target; however, IDH management is sometimes needed. Different obstacles require further clinical research.

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.

Enhancing the Cardiovascular Safety of Hemodialysis Care Using Multimodal Provider Education and Patient Activation Interventions: Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

End-stage kidney disease (ESKD) is treated with dialysis or kidney transplantation, with most patients with ESKD receiving in-center hemodialysis treatment. This life-saving treatment can result in cardiovascular and hemodynamic instability, with the most common form being low blood pressure during the dialysis treatment (intradialytic hypotension [IDH]). IDH is a complication of hemodialysis that can involve symptoms such as fatigue, nausea, cramping, and loss of consciousness. IDH increases risks of cardiovascular disease and ultimately hospitalizations and mortality. Provider-level and patient-level decisions influence the occurrence of IDH; thus, IDH may be preventable in routine hemodialysis care.

OBJECTIVE

This study aims to evaluate the independent and comparative effectiveness of 2 interventions-one directed at hemodialysis providers and another for patients-in reducing the rate of IDH at hemodialysis facilities. In addition, the study will assess the effects of interventions on secondary patient-centered clinical outcomes and examine factors associated with a successful implementation of the interventions.

METHODS

This study is a pragmatic, cluster randomized trial to be conducted in 20 hemodialysis facilities in the United States. Hemodialysis facilities will be randomized using a 2 × 2 factorial design, such that 5 sites will receive a multimodal provider education intervention, 5 sites will receive a patient activation intervention, 5 sites will receive both interventions, and 5 sites will receive none of the 2 interventions. The multimodal provider education intervention involved theory-informed team training and the use of a digital, tablet-based checklist to heighten attention to patient clinical factors associated with increased IDH risk. The patient activation intervention involves tablet-based, theory-informed patient education and peer mentoring. Patient outcomes will be monitored during a 12-week baseline period, followed by a 24-week intervention period and a 12-week postintervention follow-up period. The primary outcome of the study is the proportion of treatments with IDH, which will be aggregated at the facility level. Secondary outcomes include patient symptoms, fluid adherence, hemodialysis adherence, quality of life, hospitalizations, and mortality.

RESULTS

This study is funded by the Patient-Centered Outcomes Research Institute and approved by the University of Michigan Medical School's institutional review board. The study began enrolling patients in January 2023. Initial feasibility data will be available in May 2023. Data collection will conclude in November 2024.

CONCLUSIONS

The effects of provider and patient education on reducing the proportion of sessions with IDH and improving other patient-centered clinical outcomes will be evaluated, and the findings will be used to inform further improvements in patient care. Improving the stability of hemodialysis sessions is a critical concern for clinicians and patients with ESKD; the interventions targeted to providers and patients are predicted to lead to improvements in patient health and quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03171545; https://clinicaltrials.gov/ct2/show/NCT03171545.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46187.

Multilayer Perceptron-Based Real-Time Intradialytic Hypotension Prediction Using Patient Baseline Information and Heart-Rate Variation

Intradialytic hypotension (IDH) is a common side effect that occurs during hemodialysis and poses a great risk for dialysis patients. Many studies have been conducted so far to predict IDH, but most of these could not be applied in real-time because they used only underlying patient information or static patient disease information. In this study, we propose a multilayer perceptron (MP)-based IDH prediction model using heart rate (HR) information corresponding to time-series information and static data of patients. This study aimed to validate whether HR differences and HR slope information affect real-time IDH prediction in patients undergoing hemodialysis. Clinical data were collected from 80 hemodialysis patients from 9 September to 17 October 2020, in the artificial kidney room at Yeungnam University Medical Center (YUMC), Daegu, South Korea. The patients typically underwent hemodialysis 12 times during this period, 1 to 2 h per session. Therefore, the HR difference and HR slope information within up to 1 h before IDH occurrence were used as time-series input data for the MP model. Among the MP models using the number and data length of different hidden layers, the model using 60 min of data before the occurrence of two layers and IDH showed maximum performance, with an accuracy of 81.5%, a true positive rate of 73.8%, and positive predictive value of 87.3%. This study aimed to predict IDH in real-time by continuously supplying HR information to MP models along with static data such as age, diabetes, hypertension, and ultrafiltration. The current MP model was implemented using relatively limited parameters; however, its performance may be further improved by adding additional parameters in the future, further enabling real-time IDH prediction to play a supporting role for medical staff.

Impact of dialysate sodium concentration on vascular refilling

BACKGROUND

Although relationship between dialysate sodium concentration and hemodynamic stability has been well studied over the years, outcomes of absolute blood volume (ABV) maintenance and vascular refilling volume (V_ref ) modifications were not included, as its analysis has not been easily accessible to direct investigation. However, recent studies report a simple and feasible methodology to assess ABV and V_ref during hemodialysis (HD) treatments. It is the aim of this study to analyze whether sodium concentration in dialysate modifies ABV drop and V_ref .

METHODS

The study was performed in 19 patients under HD. During three different sessions, sodium concentration in dialysate was randomized to three different profiles: low sodium concentration (LNa, 138 mEq/L), neutral sodium concentration (NNa, 140 mEq/L), and high sodium concentration (HNa, 143 mEq/L). ABV and V_ref were calculated using Kron et al methodology.

RESULTS

Predialysis values of the measured parameters showed similar results for the three profiles. Sodium concentration showed an effect on ABV drop, V_ref, and vascular refilling fraction (F_ref ). Pair-wise comparison revealed mean ABV decreased 0.21 L less when using HNa profile versus LNa profile (p = 0.027), a mean V_ref increase of 0.39 L (p = 0.038), and a mean F_ref increase of 9.94% (p = 0.048).

CONCLUSIONS

This study shows that the use of HNa profiles increases V_ref and F_ref and reduces ABV drop during dialysis treatments when compared to LNa profiles.

Dataset supporting blood pressure prediction for the management of chronic hemodialysis

Hemodialysis (HD) is a treatment given to patients with renal failure. Notable treatment-related complications include hypotension, cramps, insufficient blood flow, and arrhythmia. Most complications are associated with unstable blood pressure during HD. Physicians are devoted to seeking solutions to prevent or lower the incidence of possible complications. With advances in technology, big data have been obtained in various medical fields. The accumulated dialysis records in each HD session can be gathered to obtain big HD data with the potential to assist HD staff in increasing patient wellbeing. We generated a large stream of HD parameters collected from dialysis equipment associated with the Vital Info Portal gateway and correlated with the demographic data stored in the hospital information system from each HD session. We expect that the application of HD big data will greatly assist HD staff in treating intradialytic hypotension, setting optimal dialysate parameters, and even developing an intelligent early-warning system as well as providing individualized suggestions regarding dialysis settings in the future.

Renal Association Clinical Practice Guideline on Haemodialysis

This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: "what does good quality haemodialysis look like?"The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to - most of this is freely available online, at least in summary form.A few notes on the individual sections: 1. This section is about how much dialysis a patient should have. The effectiveness of dialysis varies between patients because of differences in body size and age etc., so different people need different amounts, and this section gives guidance on what defines "enough" dialysis and how to make sure each person is getting that. Quite a bit of this section is very technical, for example, the term "eKt/V" is often used: this is a calculation based on blood tests before and after dialysis, which measures the effectiveness of a single dialysis session in a particular patient. 2. This section deals with "non-standard" dialysis, which basically means anything other than 3 times per week. For example, a few people need 4 or more sessions per week to keep healthy, and some people are fine with only 2 sessions per week - this is usually people who are older, or those who have only just started dialysis. Special considerations for children and pregnant patients are also covered here. 3. This section deals with membranes (the type of "filter" used in the dialysis machine) and "HDF" (haemodiafiltration) which is a more complex kind of dialysis which some doctors think is better. Studies are still being done, but at the moment we think it's as good as but not better than regular dialysis. 4. This section deals with fluid removal during dialysis sessions: how to remove enough fluid without causing cramps and low blood pressure. Amongst other recommendations we advise close collaboration with patients over this. 5. This section deals with dialysate, which is the fluid used to "pull" toxins out of the blood (it is sometimes called the "bath"). The level of things like potassium in the dialysate is important, otherwise too much or too little may be removed. There is a section on dialysate buffer (bicarbonate) and also a section on phosphate, which occasionally needs to be added into the dialysate. 6. This section is about anticoagulation (blood thinning) which is needed to stop the circuit from clotting, but sometimes causes side effects. 7. This section is about certain safety aspects of dialysis, not seeking to replace well-established local protocols, but focussing on just a few where we thought some national-level guidance would be useful. 8. This section draws together a few aspects of dialysis which don't easily fit elsewhere, and which impact on how dialysis feels to patients, rather than the medical outcome, though of course these are linked. This is where home haemodialysis and exercise are covered. There is an appendix at the end which covers a few aspects in more detail, especially the mathematical ideas. Several aspects of dialysis are not included in this guideline since they are covered elsewhere, often because they are aspects which affect non-dialysis patients too. This includes: anaemia, calcium and bone health, high blood pressure, nutrition, infection control, vascular access, transplant planning, and when dialysis should be started.

Timing of blood pressure medications and intradialytic hypotension

Intradialytic hypotension (IDH) is a prevalent yet serious complication of hemodialysis, associated with decreased quality of life, inadequate dialysis, vascular access thrombosis, global hypoperfusion, and increased cardiovascular and all-cause mortality. Current guidelines recommend antihypertensive medications be given at night and held the morning of dialysis for affected patients. Despite little evidence to support this recommendation, more than half of patients on dialysis may employ some form of this method. In this article, we will review the available evidence and clinical considerations regarding timing of blood pressure medications and occurrence of IDH, and conclude that witholding BP medications before hemodialysis should not be a routine practice.

Individualization of Ultrafiltration in Hemodialysis

OBJECTIVES

There are approximately 660 000 end-stage renal disease patients in the USA, with hemodialysis (HD) the primary form of treatment. High ultrafiltration rates (UFRs) are associated with intradialytic hypotension, a complication associated with adverse clinical outcomes including mortality. Individualized UFR profiles could reduce the incidence of intradialytic hypotension.

METHODS

The patient's fluid dynamics during HD is described by a nonlinear model comprising intravascular and interstitial pools, whose parameters are given by the patient's estimated nominal parameter values with uncertainty ranges; the output measurement is hematocrit. We design UFR profiles that minimize the maximal UFR needed to remove a prescribed volume of fluid within a set time, with hematocrit not exceeding a specified time-varying critical profile.

RESULTS

We present a novel approach to design individualized UFR profiles, and give theoretical results guaranteeing that the system remains within a predefined physiologically plausible region and does not exceed a specified time-invariant critical hematocrit level for all parameters in the uncertainty ranges. We test the performance of our design using a real patient data example. The designed UFR maintains the system below a time-varying critical hematocrit profile in the example.

CONCLUSION

Theoretical results and simulations show that our designed UFR profiles can remove the target amount of fluid in a given time period while keeping the hematocrit below a specified critical profile.

SIGNIFICANCE

Individualization of UFR profiles is now feasible using current HD technology and may reduce the incidence of intradialytic hypotension.

Intelligent system to predict intradialytic hypotension in chronic hemodialysis

BACKGROUND

Intradialytic hypotension (IDH) is a serious complication and a major risk factor of increased mortality during hemodialysis (HD). However, predicting the occurrence of intradialytic blood pressure (BP) fluctuations clinically is difficult. This study aimed to develop an intelligent system with capability of predicting IDH.

METHODS

In developing and training the prediction models in the intelligent system, we used a database of 653 HD outpatients who underwent 55,516 HD treatment sessions, resulting in 285,705 valid BP records. We built models to predict IDH at the next BP check by applying time-dependent logistic regression analyses.

RESULTS

Our results showed the sensitivity of 86% and specificity of 81% for both nadir systolic BP (SBP) of <90 mmHg and <100 mmHg, suggesting good performance of our prediction models. We obtained similar results in validating via test data and data of newly enrolled patients (new-patient data), which is important for simulating prospective situations wherein dialysis staff are unfamiliar with new patients. This compensates for the retrospective nature of the BP records used in our study.

CONCLUSION

The use of this validated intelligent system can identify patients who are at risk of IDH in advance, which may facilitate well-timed personalized management and intervention.

Measuring the prevalence of intradialytic hypotension in a satellite dialysis clinic: Are we too complacent?

AIMS AND OBJECTIVES

To measure the prevalence of symptomatic (S-IDH) and asymptomatic intradialytic hypotension (A-IDH) or postdialysis overhydration in a satellite haemodialysis clinic in Western Australia.

BACKGROUND

Intradialytic hypotension is one of the most common side effects of haemodialysis caused by ultrafiltration provoking a temporary volume depletion. The prevalence of asymptomatic hypotension during dialysis has been rarely reported, but is considered to have the same negative consequences as symptomatic hypotension on various end organs like the brain and the gastrointestinal tract.

DESIGN

Observational study on a retrospective 3-month period of nursing recorded fluid-related adverse events.

METHODS

Data collection on the occurrence of S-IDH and A-IDH during a total of 2,357 haemodialysis treatments in 64 patients. Body weight of patients at the time of cessation of treatment was recorded, and patients, whose weight exceeded their ideal body weight by at least 0.5 kg, were classified as overhydrated. Data analysis was performed using spss version 24 software.

RESULTS

Symptomatic intradialytic hypotension was the most common adverse event measured in this cohort, and occurred during 221 (9.4%) of all treatments, whereas asymptomatic intradialytic hypotension occurred in 88 (3.7%) of all treatments. The total occurrence of intradialytic hypotension was 13.1%, and symptomatic was observed in 30 patients, implying that nearly every second patient had at least one symptomatic episode within 3 months. Overhydration occurred in a total of 103 (4.4%) of all treatments, and involved 17 patients.

CONCLUSIONS

Symptomatic and asymptomatic intradialytic hypotension were the most commonly observed adverse events in this cohort; overhydration occurrence was considerably less common.

RELEVANCE TO CLINICAL PRACTICE

The high occurrence of hypotension-related events demonstrates that ultrafiltration treatment goals in satellite dialysis clinics are sometimes overestimated, resulting in regular significant symptomatic episodes for the patient. Raising the awareness of the prevalence of IDH amongst renal nurses could be an essential initial step before collectively preventative strategies in haemodialysis satellite units are implemented.

Evaluation of Intradialytic Hypertension Using Bioelectrical Impedance Combined With Echocardiography in Maintenance Hemodialysis Patients

Although intra-dialytic hypertension (IDH) has been noted in clinical settings for many years, its pathogenesis remains unclear. In this cross-sectional study, we analyzed IDH incidence in our center and the correlation between postdialysis volume state and IDH. One hundred thirty-one maintenance hemodialysis (MHD) patients were enrolled in our study, and bioelectrical impedance (BIA) and echocardiography (ECG) were recorded. In addition, demographic data were collected, and laboratory examinations were conducted. The patients were grouped into four groups according to the change in systolic blood pressure (SBP) between predialysis and postdialysis. The incidence of IDH was 10.7%. The proportion of extracellular water to total body weight (ECW/TW), as evaluated by BIA, was significantly higher in the IDH group than in the other three groups both in pre-and post-dialysis. In particular, postdialysis SBP was highest in the highest tertile interval of ECW/TW. In addition, among the four groups, left ventricular volume (LVV) was highest in the IDH group. Binary logistic analyses revealed that predialysis SBP, postdialysis ECW/TW and LVV were independent risk factors of intradialytic hypertension. When predicting IDH, the AUC of the ROC curve was higher for ECW/TW combined with LVV (0.752, 95% CI 0.613-0.896) than for either LVV or ECW/TW alone. Our study further showed that post-dialysis volume expansion is an important factor for the development of IDH.

Use of ultrasound by registered nurses-a systematic literature review

BACKGROUND

In Western Australia (WA), most stable patients undergoing haemodialysis receive treatment in a satellite setting where no doctors are on-site during treatment hours, so nurses must make critical decisions about fluid removal. Some patients regularly experience adverse events during dialysis (intradialytic), often due to excessive ultrafiltration goals, with intradialytic hypotension being particularly challenging. Ultrasound of the inferior vena cava has been previously demonstrated being a rapid and non-invasive method for volume assessment on haemodialysis patients, thus could hold valuable information for the treating nurse.

AIM

This paper examines the existing literature in regards to the use of ultrasound measurements of the inferior vena cava in patients on haemodialysis for objective assessment of their intravascular volume status by renal nurses.

METHOD

A systematic literature review was performed within medical and nursing databases including CINAHL Plus with Full Text, SCOPUS, Web of Science and MEDLINE.

RESULTS

Renal nurses are conscious of the significance of intradialytic hypotension and have only limited options for its prevention. Ultrasound of the inferior vena cava could add another objective dimension for intravascular volume assessment and prevention of intradialytic hypotension, but to date renal nurses have not been using this technique.

CONCLUSIONS

Ultrasound of the inferior vena cava has the potential to assist in defining the ultrafiltration goal for that particular dialysis session, thus reducing the risk of intradialytic hypotension. Additionally, it has potential to change current renal nursing practice when added to clinical nursing assessment methods. Further studies are required to validate this assessment tool carried out by a renal nurse compared with a skilled ultrasonographer.

We Hold Antihypertensives Prior To Dialysis

Hypertension is the most common complication of end-stage renal disease and chronic hemodialysis and yet, only a third of these patients have adequately controlled blood pressures. Pathogenesis of hypertension in this population is complex and multifactorial and therefore poses numerous treatment challenges. Furthermore, it is common practice among nephrologists to withhold antihypertensives prior to a hemodialysis procedure due to concerns for intradialytic hypotension (IDH). Intradialytic hypertension (ID-HTN) is an increasingly recognized phenomenon and although less common than IDH, portends poor cardiovascular prognosis as well as reflects higher hypertension burden in the dialysis population. Withholding antihypertensives prior to dialysis routinely in patients may worsen interdialytic blood pressure control as well as increase the prevalence of euvolemic ID-HTN. It may also increase the risk of cardiac arrhythmias and further compromise hemodynamic stability during dialysis. In such situations, predialysis administration of antihypertensive is appropriate and necessary and drug choice should be based on the patient's comorbidities, pharmacokinetics of the drug and its dialyzability.

Computer Aided Detection System for Prediction of the Malaise during Hemodialysis

Monitoring of dialysis sessions is crucial as different stress factors can yield suffering or critical situations. Specialized personnel is usually required for the administration of this medical treatment; nevertheless, subjects whose clinical status can be considered stable require different monitoring strategies when compared with subjects with critical clinical conditions. In this case domiciliary treatment or monitoring can substantially improve the quality of life of patients undergoing dialysis. In this work, we present a Computer Aided Detection (CAD) system for the telemonitoring of patients' clinical parameters. The CAD was mainly designed to predict the insurgence of critical events; it consisted of two Random Forest (RF) classifiers: the first one (RF₁) predicting the onset of any malaise one hour after the treatment start and the second one (RF₂) again two hours later. The developed system shows an accurate classification performance in terms of both sensitivity and specificity. The specificity in the identification of nonsymptomatic sessions and the sensitivity in the identification of symptomatic sessions for RF₂ are equal to 86.60% and 71.40%, respectively, thus suggesting the CAD as an effective tool to support expert nephrologists in telemonitoring the patients.

Euvolemia in hemodialysis patients: a potentially dangerous goal?

Dialysis patients have high mortality rate and the leading cause of death is cardiovascular disease. Uremic cardiomyopathy differs from that due to conventional atherosclerosis, where cardiovascular changes result in ineffective circulation and lead to tissue ischemia. Modern dialysis has significant limitations with fluid management probably the most challenging. Current evidence suggests that both volume overload and aggressive fluid removal can induce circulatory stress and multi-organ injury. Furthermore, we do not have accurate volume assessment tools. As a result, targeting euvolemia might result in more harm than benefit with conventional hemodialysis therapy. Therefore, it might be time to consider a degree of permissive over-hydration until we have better tools to both determine ideal weight and improve current renal replacement therapy so that the process of achieving it is not so fraught with the current dangers.

Attending rounds: A patient with intradialytic hypotension

Intradialytic hypotension is the most common adverse event that occurs during the hemodialysis procedure. Despite advances in machine technology, it remains a difficult management issue. The pathophysiology of intradialytic hypotension and measures to reduce its frequency are discussed. An accurate assessment of dry weight is crucial in all patients on dialysis and especially those patients prone to intradialytic hypotension. The presence of edema and hypertension has recently been shown to be a poor predictor of volume overload. Noninvasive methods to assess volume status, such as whole body and segmental bioimpedance, hold promise to more accurately assess fluid status. Reducing salt intake is key to limiting interdialytic weight gain. A common problem is that patients are often told to restrict fluid but not salt intake. Lowering the dialysate temperature, prohibiting food ingestion during hemodialysis, and midodrine administration are beneficial. Sodium modeling in the absence of ultrafiltration modeling should be abandoned. There is not enough data on the efficacy of l-carnitine to warrant its routine use.