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Wu Y, Lu J, Wang T, Zhu X, Xue J, You L. Association of frequent intradialytic hypotension with the clinical outcomes of patients on hemodialysis: a prospective cohort study. Ren Fail 2024; 46:2296612. [PMID: 38178566 PMCID: PMC10773638 DOI: 10.1080/0886022x.2023.2296612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 12/12/2023] [Indexed: 01/06/2024] Open
Abstract
Intradialytic hypotension (IDH) is a common complication of hemodialysis (HD), but there is no consensus on its definition. In 2015, Flythe proposed a definition of IDH (Definition 1 in this study): nadir systolic blood pressure (SBP) <90 mmHg during hemodialysis for patients with pre-dialysis SBP <159 mmHg, and nadir SBP <100 mmHg during hemodialysis for patients with pre-dialysis SBP ≥160 mmHg. This prospective observational cohort study investigated the association of frequent IDH based on Definition 1 with clinical outcomes and compared Definition 1 with a commonly used definition (nadir SBP <90 mmHg during hemodialysis, Definition 2). The incidence of IDH was observed over a 3-month exposure assessment period. Patients with IDH events ≥30% were classified as 'frequent IDH'; the others were 'infrequent IDH'. All-cause mortality, cardiovascular mortality, and all-cause hospitalization events were followed up for 36 months. This study enrolled 163 HD patients. The incidence of IDH was 11.1% according to Definition 1 and 10.5% according to Definition 2. The Kaplan-Meier curves showed that frequent IDH patients had higher risks of all-cause mortality (p = 0.009, Definition 1; p = 0.002, Definition 2) and cardiovascular mortality (p = 0.021, Definition 1). Multivariable Cox regression analysis indicated that frequent IDH was independently associated with a higher risk of all-cause mortality (Model 1: HR = 2.553, 95%CI 1.334-4.886, p = 0.005; Model 2: HR = 2.406, 95%CI 1.253-4.621, p = 0.008). In conclusion, HD patients classified as frequent IDH are at a greater risk of all-cause mortality. This highlights the significance of acknowledging and proactively managing frequent IDH within the HD patients.
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Affiliation(s)
- Yuanhao Wu
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Jianda Lu
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Tingting Wang
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Xiaoye Zhu
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Jun Xue
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Li You
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
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Wang J, Yao J, Zhu X, Wang T, Lu J, Wei Q, Xue J, Wu Y, You L. Impact of frequent intradialytic hypotension on quality of life in patients undergoing hemodialysis. BMC Nephrol 2023; 24:209. [PMID: 37452301 PMCID: PMC10347841 DOI: 10.1186/s12882-023-03263-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Intradialytic hypotension (IDH) is frequently accompanied by symptoms of nausea, dizziness, fatigue, muscle spasm, and arrhythmia, which can adversely impact the daily lives of patients who undergo hemodialysis and may lead to decreased quality of life (QoL). This study employed the KDQOL™-36 scale to evaluate the impact of frequent IDH, based on the definition determined by predialysis blood pressure (BP) and nadir systolic blood pressure (SBP) thresholds, on the QoL of patients. METHODS This is a single center retrospective cohort study involving 160 hemodialysis patients. We enrolled adult patients with uremia who received routine hemodialysis (4 h/time, 3 times/week) from October 1, 2019, to September 30, 2021. Frequent IDH was defined as an absolute nadir SBP < 90 mmHg occurring in no less than 30% of hemodialysis sessions when predialysis SBP < 159 mmHg (or < 100 mmHg when predialysis BP ≥ 160 mmHg).The differences between patients with and without frequent IDH were compared using the independent t test, Kruskal‒Wallis test, or chi-square test. The primary visit was at month 36, and the remaining visits were exploratory outcomes. RESULTS Compared to patients with infrequent IDH at baseline, those with frequent IDH had significantly lower scores on the symptoms and discomfort of kidney disease dimension at all follow-up points (P < 0.05). The symptoms and discomfort of kidney disease dimension were worse in patients with frequent IDH. Those with frequent IDH had a significantly poorer QoL regarding the dimensions of symptoms and discomfort of kidney disease and the impact of kidney disease on life. CONCLUSIONS The findings of the study suggest an association between frequent IDH and QoL dimensions of symptoms and discomfort of kidney disease and the impact of kidney disease on life dimension under the definition of frequent IDH.
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Affiliation(s)
- Jianhua Wang
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Baoshan Branch, Shanghai, China
| | - Jing Yao
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Baoshan Branch, Shanghai, China
| | - Xiaoye Zhu
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Baoshan Branch, Shanghai, China
| | - Tingting Wang
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Baoshan Branch, Shanghai, China
| | - Jianda Lu
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Baoshan Branch, Shanghai, China
| | - Qiubo Wei
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Baoshan Branch, Shanghai, China
| | - Jun Xue
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Baoshan Branch, Shanghai, China
| | - Yuanhao Wu
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Baoshan Branch, Shanghai, China
| | - Li You
- Department of Nephrology, Huashan Hospital Affiliated to Fudan University, Baoshan Branch, Shanghai, China
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Veinot TC, Gillespie B, Argentina M, Bragg-Gresham J, Chatoth D, Collins Damron K, Heung M, Krein S, Wingard R, Zheng K, Saran R. Enhancing the Cardiovascular Safety of Hemodialysis Care Using Multimodal Provider Education and Patient Activation Interventions: Protocol for a Cluster Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e46187. [PMID: 37079365 PMCID: PMC10160944 DOI: 10.2196/46187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 02/19/2023] [Indexed: 02/21/2023] Open
Abstract
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.
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Affiliation(s)
- Tiffany Christine Veinot
- School of Information, University of Michigan, Ann Arbor, MI, United States
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, United States
- Department of Learning Health Sciences, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Brenda Gillespie
- Department of Biostatistics, Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, MI, United States
| | | | - Jennifer Bragg-Gresham
- Division of Nephrology, School of Medicine, Ann Arbor, MI, United States
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI, United States
| | | | | | - Michael Heung
- Division of Nephrology, School of Medicine, Ann Arbor, MI, United States
| | - Sarah Krein
- Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI, United States
- Veterans Affairs Center for Clinical Management Research, US Department of Veterans Affairs, Ann Arbor, MI, United States
| | | | - Kai Zheng
- School of Information and Computer Sciences, University of California Irvine, Irvine, CA, United States
| | - Rajiv Saran
- Division of Nephrology, School of Medicine, Ann Arbor, MI, United States
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI, United States
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Allinovi M, Palazzini G, Lugli G, Gianassi I, Dallari L, Laudicina S, Gregori M, Rossi F, Giannerini D, Cutruzzulà R, Dervishi E, Biagini M, Cirami CL. Pre-Dialysis B-Line Quantification at Lung Ultrasound Is a Useful Method for Evaluating the Dry Weight and Predicting the Risk of Intradialytic Hypotension. Diagnostics (Basel) 2022; 12:diagnostics12122990. [PMID: 36552997 PMCID: PMC9776885 DOI: 10.3390/diagnostics12122990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/22/2022] [Accepted: 11/26/2022] [Indexed: 12/02/2022] Open
Abstract
Intradialytic hypotension (IDH) is a frequent and well-known complication of hemodialysis, occurring in about one third of patients. An integrated approach with different methods is needed to minimize IDH episodes and their complications. In this prospective observational study, recruited patients underwent a multiparametric evaluation of fluid status through a lung ultrasound (LUS) with the quantification of B-lines, a physical examination, blood pressure, NT-proBNP and chest X-rays. The evaluation took place immediately before and at the end of the dialysis session, and the patients were divided into IDH and no-IDH groups. We recruited a total of 107 patients. A pre-dialysis B-line number ≥ 15 showed a high sensitivity in fluid overload diagnosis (94.5%), even higher than a chest X-ray (78%) or physical examination (72%) alone. The identification at the beginning of dialysis of <8 B-lines in the overall cohort or <20 B-lines in patients with NYHA 3−4 class are optimal thresholds for identifying those patients at higher risk of experiencing an IDH episode. In the multivariable analysis, the NYHA class, a low pre-dialysis systolic BP and a low pre-dialysis B-line number were independent risk factors for IDH. At the beginning of dialysis, the B-line quantification at LUS is a valuable and reliable method for evaluating fluid status and predicting IDH episodes. A post-dialysis B-line number <5 may allow for an understanding of whether the IDH episode was caused by dehydration, probably due to due to an overestimation of the dry weight.
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Affiliation(s)
- Marco Allinovi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
- Correspondence:
| | - Giulia Palazzini
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, 50121 Florence, Italy
| | - Gianmarco Lugli
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, 50121 Florence, Italy
- Nephrology Unit, Meyer Children’s Hospital, 50139 Florence, Italy
| | - Iacopo Gianassi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Lorenzo Dallari
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, 50121 Florence, Italy
| | - Selene Laudicina
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, 50121 Florence, Italy
| | - Marco Gregori
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, 33076 Bordeaux, France
| | - Francesco Rossi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Daniele Giannerini
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Roberta Cutruzzulà
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Egrina Dervishi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Maria Biagini
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
| | - Calogero Lino Cirami
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Largo Brambilla, 3, 50134 Florence, Italy
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Kamjohnjiraphunt N, Trakarnvanich T. Bioelectrical impedance analysis versus physician adjustment in acute kidney injury patients to reduce intradialytic hypotension: A randomized controlled trial. Ann Med Surg (Lond) 2022; 80:104311. [PMID: 35992204 PMCID: PMC9389256 DOI: 10.1016/j.amsu.2022.104311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/27/2022] [Accepted: 07/27/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Methods Result Conclusion Intradialytic hypotension is common during hemodialysis. Bioimpedance spectroscopy can help assess fluid status in critically ill patients. BIA-guided protocol can reduce significantly the incidence of IDH compared to conventional method.
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Affiliation(s)
| | - Thananda Trakarnvanich
- Corresponding author. Renal Unit, Department of Medicine, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, 681 Samsen Road, Dusit, Bangkok, 10300, Thailand.
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Wong A, Robinson L, Soroush S, Suresh A, Yang D, Madu K, Harhay MN, Pourrezaei K. Assessment of cerebral oxygenation response to hemodialysis using near-infrared spectroscopy (NIRS): Challenges and solutions. J Innov Opt Health Sci 2021; 14:2150016. [PMID: 35173820 PMCID: PMC8846418 DOI: 10.1142/s1793545821500164] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
To date, the clinical use of functional near-infrared spectroscopy (NIRS) to detect cerebral ischemia has been largely limited to surgical settings, where motion artifacts are minimal. In this study, we present novel techniques to address the challenges of using NIRS to monitor ambulatory patients with kidney disease during approximately eight hours of hemodialysis (HD) treatment. People with end-stage kidney disease who require HD are at higher risk for cognitive impairment and dementia than age-matched controls. Recent studies have suggested that HD-related declines in cerebral blood flow might explain some of the adverse outcomes of HD treatment. However, there are currently no established paradigms for monitoring cerebral perfusion in real-time during HD treatment. In this study, we used NIRS to assess cerebral hemodynamic responses among 95 prevalent HD patients during two consecutive HD treatments. We observed substantial signal attenuation in our predominantly Black patient cohort that required probe modifications. We also observed consistent motion artifacts that we addressed by developing a novel NIRS methodology, called the HD cerebral oxygen demand algorithm (HD-CODA), to identify episodes when cerebral oxygen demand might be outpacing supply during HD treatment. We then examined the association between a summary measure of time spent in cerebral deoxygenation, derived using the HD-CODA, and hemodynamic and treatment-related variables. We found that this summary measure was associated with intradialytic mean arterial pressure, heart rate, and volume removal. Future studies should use the HD-CODA to implement studies of real-time NIRS monitoring for incident dialysis patients, over longer time frames, and in other dialysis modalities.
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Affiliation(s)
- Ardy Wong
- Drexel University School of Bioengineering, Philadelphia, Pennsylvania
| | - Lucy Robinson
- Department of Epidemiology & Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania
| | - Seena Soroush
- Drexel University College of Arts and Sciences, Philadelphia, Pennsylvania
| | - Aditi Suresh
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Dia Yang
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Kelechi Madu
- Drexel University School of Bioengineering, Philadelphia, Pennsylvania
| | - Meera N. Harhay
- Department of Epidemiology & Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
- Tower Health Transplant Institute, Tower Health System, West Reading, Pennsylvania
| | - Kambiz Pourrezaei
- Drexel University School of Bioengineering, Philadelphia, Pennsylvania
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Dasgupta I, Odudu A, Baharani J, Fergusson N, Griffiths H, Harrison J, Maruff P, Thomas GN, Woodhall G, Youseff S, Tadros G. Evaluation of the effect of Cooled HaEmodialysis on Cognitive function in patients suffering with end-stage KidnEy Disease (E-CHECKED): feasibility randomised control trial protocol. Trials 2020; 21:820. [PMID: 32998761 PMCID: PMC7526411 DOI: 10.1186/s13063-020-04725-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/03/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cognitive impairment is common in haemodialysis (HD) patients and is associated independently with depression and mortality. This association is poorly understood, and no intervention is proven to slow cognitive decline. There is evidence that cooler dialysis fluid (dialysate) may slow white matter changes in the brain, but no study has investigated the effect of cooler dialysate on cognition. This study addresses whether cooler dialysate can prevent the decline in cognition and improve quality of life (QOL) in HD patients. METHODS This is a multi-site prospective randomised, double-blinded feasibility trial. SETTING Four HD units in the UK. PARTICIPANTS AND INTERVENTIONS Ninety HD patients randomised (1:1) to standard care (dialysate temperature 36.5 °C) or intervention (dialysate temperature 35 °C) for 12 months. PRIMARY OUTCOME MEASURE Change in cognition using the Montreal Cognitive Assessment (MoCA). SECONDARY OUTCOME MEASURES Recruitment and attrition rates, reasons for non-recruitment, frequency of intradialytic hypotension, depressive symptom scores, patient and carers burden, a detailed computerised cognitive test and QOL assessments. ANALYSIS mixed method approach, utilising measurement of cognition, questionnaires, physiological measurements and semi-structured interviews. DISCUSSION The results of this feasibility trial will inform the design of a future adequately powered substantive trial investigating the effect of dialysate cooling on prevention and/or slowing in cognitive decline in patients undergoing haemodialysis using a computerised battery of neuro-cognitive tests. The main hypothesis that would be tested in this future trial is that patients treated with regular conventional haemodialysis will have a lesser decline in cognitive function and a better quality of life over 1 year by using cooler dialysis fluid at 35 °C, versus a standard dialysis fluid temperature of 36.5 °C. This also should reflect in improvements in their abilities for activities of daily living and therefore reduce carers' burden. If successful, the treatment could be universally applied at no extra cost. TRIAL REGISTRATION ClinicalTrials.gov NCT03645733 . Registered retrospectively on 24 August 2018.
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Affiliation(s)
- Indranil Dasgupta
- Renal Unit, Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, UK. .,Warwick Medical School, University of Warwick, Coventry, UK.
| | - Aghogho Odudu
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK.,Manchester University NHS Foundation Trust, Manchester, UK
| | - Jyoti Baharani
- Renal Unit, Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, UK
| | - Niall Fergusson
- Department of Care of the Elderly, Heartlands Hospital, Birmingham, UK
| | - Helen Griffiths
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - John Harrison
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | | | - G Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gavin Woodhall
- School of Neuropharmacology, Aston University, Birmingham, UK
| | | | - George Tadros
- Department of Old Age Psychiatry, Heartlands Hospital, Birmingham, UK.,Aston Medical School, Aston University, Birmingham, UK
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Correa S, Pena-Esparragoza JK, Scovner KM, Mc Causland FR. Predictors of Intradialytic Symptoms: An Analysis of Data From the Hemodialysis Study. Am J Kidney Dis 2020; 76:331-339. [DOI: 10.1053/j.ajkd.2020.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 01/05/2020] [Indexed: 11/11/2022]
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10
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McIntyre D, Havas K, Bonner A. Monitoring for intradialytic hypotension: An audit of nursing practice. J Ren Care 2020; 47:27-33. [PMID: 32734685 DOI: 10.1111/jorc.12343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intradialytic hypotension (IDH) is one of the most common complications associated with haemodialysis (HD), yet the frequency of patient assessment by nurses varies in practice. We sought to measure the frequency of nursing assessments before, during and after HD and to identify any predictors of IDH. OBJECTIVES To audit the frequency, nursing management and contributing factors of IDH. DESIGN A prospective clinical audit was undertaken over 4 weeks. PARTICIPANTS Nurses completed audit sheets on 132 patients at three chronic HD units. MEASUREMENTS The audit tool consisted of 34 questions related to demographics, HD prescription, frequency of monitoring and nursing interventions. RESULTS A total of 1584 sessions were performed with 876 (55.3%) audits returned, of which 452 were useable. There were 74 actual episodes of IDH, and a further 72 potential episodes may have been prevented due to nursing intervention. Most nurses reported assessing patients before starting HD and as required before an actual or potential IDH event (n = 85; 63%); few hourly assessments were performed. Predictors of IDH were systolic blood pressure ≤140 mmHg, having more than four comorbidities, dialysate temperature > 36°C, calcium < 1.3 mmol/L and a shorter dialysis session (3.0-4.5 h). These predictors explained 14.1% of the variance in hypotensive episodes during HD. CONCLUSION This clinical audit highlighted the importance of assessing blood pressure trends during HD to preemptively intervene before IDH developing. The audit has resulted in a practice change to hourly assessments. Follow-up audits of practice should occur.
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Affiliation(s)
- David McIntyre
- Kidney Health Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Health, School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Kathryn Havas
- Faculty of Health, School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ann Bonner
- Kidney Health Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Health, School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
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11
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Ozen N, Cepken T. Intradialytic hypotension prevalence, influencing factors, and nursing interventions: prospective results of 744 hemodialysis sessions. Ir J Med Sci 2020; 189:1471-1476. [PMID: 32447597 DOI: 10.1007/s11845-020-02249-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 05/03/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The aim of this study was to evaluate intradialytic hypotension (IDH) prevalence, influencing factors, and nursing interventions in hemodialysis (HD) patients. METHODS This descriptive and cross-sectional study was conducted at a private dialysis center. The patients were followed-up in terms of IDH development based on the European Best Practice Guidelines criteria during six consecutive HD sessions. The study followed the STROBE checklist. RESULTS A total of 744 hemodialysis sessions of 124 patients were monitored. IDH developed in 51.6% of the patients and the prevalence was 17.60%. The most common nursing interventions were stopping ultrafiltration and isotonic saline solution administration. White blood cell (WBC) (p = 0.017) and creatinine (p = 0.005) values were statistically significantly higher in patients developing IDH. WBC was found to increase IDH development risk 0.796 times (95% CI [0.657-0.996], p = 0.021). CONCLUSION Nursing staff awareness regarding the frequency of IDH in hemodialysis patients and the related symptoms needs to be increased.
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Affiliation(s)
- Nurten Ozen
- Florence Nightingale Hospital School of Nursing, Demiroglu Bilim University, Istanbul, Turkey.
| | - Tugba Cepken
- Private Esenyurt Dialysis Center, Istanbul, Turkey
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12
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Yoowannakul S, Vongsanim S, Kotecha T, Fontana M, Davenport A. Hemodialysis patients with less extracellular water overload and smaller cardiac atrial chamber sizes are at greater risk of a fall in blood pressure during dialysis. Ther Apher Dial 2020; 25:16-23. [PMID: 32216122 DOI: 10.1111/1744-9987.13490] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/24/2020] [Accepted: 03/19/2020] [Indexed: 11/27/2022]
Abstract
Intradialytic hypotension is the most common complication of hemodialysis (HD) treatments. Excessive ultrafiltration results in reduced cardiac preload. We aimed to determine whether a fall in systolic blood pressure during HD was greater in patients starting HD with (a) less overhydration measured by extracellular water (ECW) and (b) lower cardiac preload by cardiac magnetic resonance imaging (MRI). Pre-HD measurements of ECW and total body water (TBW) were performed using multifrequency bioimpedance (MFBIA). Cardiac chamber sizes and functions were determined by MRI. Twenty-six patients, 18 males (69.2%), 11 (42.3%) with diabetes, mean age 63.9 ± 15.9 years were studied. Systolic blood pressure (SBP) fell in 15 (57.7%) patients, and either did not change or increased in 9. There was no difference in demographics between groups. Patients with a fall in SBP had lower pre-HD ECW/TBW (0.400 ± 0.018 vs 0.418 ± 0.021), indexed right ventricular end-diastolic volume (81.2 ± 37.6 vs 100.8 ± 33.7 mL/m2 ), and indexed left atrial size (13.7 ± 3.9 vs 18.3 ± 5.0 mL/m2 ), all P < .05, respectively. There were univariate correlations between the change in SBP and pre-HD ECW/TBW for the trunk (r = .50, P = .009) and indexed left atrial volume (r = .54, P = .005). A fall in blood pressure occurred more commonly in patients starting HD with lower overhydration as measured by bioimpedance, and those with smaller cardiac chamber sizes. Patients with the lowest ECW/TBW and smallest cardiac chamber sizes had the greatest falls in SBP. This study reinforces the importance of determining physiological target weights and avoiding inappropriately low target weights for HD patients.
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Affiliation(s)
- Suree Yoowannakul
- Department of Nephrology Royal Free Hospital, University College London, London, UK
| | - Surachet Vongsanim
- Department of Nephrology Royal Free Hospital, University College London, London, UK
| | - Tushar Kotecha
- National Amyloid Centre, Royal Free Hospital, Department of Medicine, University College London, London, UK.,Department of Cardiology, Royal Free Hospital, London, UK
| | - Marianna Fontana
- National Amyloid Centre, Royal Free Hospital, Department of Medicine, University College London, London, UK
| | - Andrew Davenport
- Department of Nephrology Royal Free Hospital, University College London, London, UK
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13
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Blum D, Beaubien-Souligny W, Silver SA, Wald R. Thinking Volume First: Developing a Multifaceted Systematic Approach to Volume Management in Hemodialysis. Can J Kidney Health Dis 2019; 6:2054358119879776. [PMID: 31598215 PMCID: PMC6764043 DOI: 10.1177/2054358119879776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/28/2019] [Indexed: 12/17/2022] Open
Abstract
Purpose of review: Volume overload and hypovolemia-induced symptoms are common in the
hemodialysis (HD) population and frequently result in emergency department
visits and hospitalization. A structured strategy for the reporting,
evaluation, and management of disordered volume status may improve clinical
outcomes and the patient experience. We developed a new strategy that
systematically addresses volume issues by leveraging the electronic medical
record, technological adjuncts, and multidisciplinary expertise to institute
new processes of care in our HD unit. Sources of information: This initiative was implemented in a unit located in an urban academic
hospital where 250 patients receive maintenance HD. This initiative involved
a multidisciplinary team of health professionals including physicians, nurse
practitioners, social workers, and dieticians. Methods: We generated volume metrics for HD recipients based on routinely collected
data from the unit’s electronic medical record. We then engaged stakeholders
in a root cause analysis to identify the major causes of abnormal volume
metrics locally. We subsequently developed interventions that were designed
to address each of the major causes in a pragmatic and sustainable
program. Key findings: The final product was a local volume management program with 3 components.
First, we integrated volume metric reporting into the routine surveillance
bloodwork reports across our unit. This enabled the clinical teams to more
easily target patients at risk for volume-related adverse events and provide
them with closer surveillance. Those identified with abnormal volume metrics
were then evaluated with the use of technologic adjuncts such as lung
ultrasound and bioimpedance spectroscopy to complement traditional
assessments of volume status. Finally, those with abnormal volume metrics
underwent rigorous interdisciplinary review for potential nutritional/social
interventions. Limitations: While we report the successful initial implementation of the program within a
single center, it remains unclear whether this initiative will lead to
meaningful benefits for HD recipients, be readily applicable in other
centers, or be sustainable in the long term. Implications: This volume management program will need further evaluation linked to outcome
assessment and feasibility in other centers before wider adoption is
advocated.
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Affiliation(s)
- Daniel Blum
- Jewish General Hospital, Montreal, QC, Canada
| | | | | | - Ron Wald
- St. Michael's Hospital, Toronto, ON, Canada
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14
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Yoowannakul S, Leung TS, Davenport A. Pilot Study to Detect Changes in Blood Flow in the External Auditory Meatus During Hemodialysis. Ther Apher Dial 2019; 24:307-311. [PMID: 31442360 DOI: 10.1111/1744-9987.13433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 07/19/2019] [Accepted: 08/20/2019] [Indexed: 11/28/2022]
Abstract
Blood flow to internal organs is reported to fall during hemodialysis (HD). As such, noninvasive monitoring devices are required to detect changes in perfusion, which could then be used for therapeutic interventions. We report on a pilot study monitoring blood flow in the outer auditory meatus. We measured the maximum pulse wave amplitude and indicators of blood flow by analyzing red and green color changes in the outer auditory meatus from video recordings made using an otoscope fitted with a digital camera during HD treatments. We studied 61 patients, 43 (71.5%) male, mean age 64.9 ± 12.7 years. Weight fell from 72.8 ± 22.5 kg predialysis to 71.5 ± 22.1 kg postdialysis (P < 0.001). BP did not significantly change (predialysis 142 ± 29/67 ± 18 to 143 ± 25/68 ± 17 mm Hg postdialysis). The maximum pulse wave amplitude in the external auditory meatus fell from 0.21 (0.1-0.55) to 0.14 (0.04-0.4) after 90 min, P < 0.001, and remained low thereafter, and the change at the end of the dialysis session was associated with percentage weight loss (r = -0.37, P = 0.003). Green and red pixel values did not change (predialysis 0.339 [0.333-0.345] to 0.302 [0.291-0.33] post, and 0.301 [0.293-0.328] predialysis to 0.339 [0.334-0.347] post, respectively). This pilot study showed that the maximum pulse wave amplitude measured in the external auditory meatus fell during the dialysis session, and that the fall was associated with fluid removal. This could potentially lead to the development of a monitoring device, which could fit in the ear and record during the dialysis session.
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Affiliation(s)
| | - Terence S Leung
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
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15
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Jeong JH, Biruete A, Fernhall B, Wilund KR. Effects of acute intradialytic exercise on cardiovascular responses in hemodialysis patients. Hemodial Int 2018; 22:524-533. [PMID: 29745006 PMCID: PMC10463186 DOI: 10.1111/hdi.12664] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 03/04/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND In patients with kidney failure requiring hemodialysis (HD) treatment, intradialytic exercise (IDEX) has been advocated for its feasibility and effectiveness in improving important health outcomes. However, IDEX as an adjunct therapeutic strategy is infrequently implemented, in part due to potential risks of IDEX, especially in patients with chronic volume overload. This study was performed to evaluate the safety of IDEX performed at different time points by examining its effect on intradialytic cardiovascular hemodynamics. METHODS In a randomized cross-over study (n = 12), intradialytic changes in brachial, aortic, and cardiac hemodynamics and autonomic function were examined during a HD session; (1) without exercise; (2) with 30 min of IDEX performed in the first hour of treatment; or (3) with 30 min of IDEX in the third hour of treatment. RESULTS IDEX during either the first or third hour did not exacerbate hemodynamic instability during treatment regardless of patient's hydrations status. While there were transient increases in stroke volume, cardiac output, and heart rate during IDEX, intradialytic changes in brachial and aortic blood pressure, cardiac hemodynamics, and autonomic function were similar on days with and without IDEX. CONCLUSION These results indicate that IDEX does not exacerbate hemodynamic instability during HD, regardless of a patient's hydration status or the timing of exercise.
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Affiliation(s)
- Jin Hee Jeong
- Department of Kinesiology and Community Health, Urbana, Illinois, USA
| | - Annabel Biruete
- Division of Nutritional Sciences, University of Illinois, Urbana-Champaign, Urbana, Illinois, USA
| | - Bo Fernhall
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kenneth R Wilund
- Department of Kinesiology and Community Health, Urbana, Illinois, USA
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16
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Jones CB, Chan CT. Boundaries of frequency and treatment time in conventional hemodialysis: Balancing convenience, economics, and health outcomes. Semin Dial 2018; 31:537-543. [PMID: 30094871 DOI: 10.1111/sdi.12742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Since the inception of hemodialysis (HD) for patients with chronic kidney disease, the "perfect" dialysis prescription has remained elusive. Part of this may relate to the heterogeneity among populations, individual patients, and differences in access to health provision. The optimal balance between dialysis frequency and duration to achieve reductions in patient morbidity and mortality continues to be debated. The concept of dialysis adequacy originated from a post hoc mathematical analysis of the National Cooperative Study and has evolved to become a way of calculating dialysis dose and standardizing the dialysis prescription. In contrast, in its originally conceived sense, dialysis adequacy referred to the effective clearance of small solutes. Given the evolution of dialysis practice, we now aim to consider dialysis adequacy in a broader and more holistic manner particularly in view of our aging population and focus toward important patient-centered outcomes. While the traditional thrice weekly, HD regimen remains the default renal replacement modality, alternative strategies including short daily HD, long conventional HD, and long nocturnal HD are being widely implemented. We aim for optimal solute clearance, effective ultrafiltration to achieve normotension (while avoiding intradialytic symptoms) and maintenance of nutritional parameters all within the caveat that quality of life and autonomy are preserved.
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Affiliation(s)
- Clare B Jones
- Division of Nephrology, University Health Network, Toronto, ON, Canada
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17
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Abstract
Intradialytic hypotension (IDH) is a common and often distressful complication of hemodialysis. However, despite its clinical significance, there is no consensus, evidence-based medical definition for the condition. Over the years, numerous definitions have been implemented in both the clinical and research settings. Definition inconsistencies have hindered data synthesis and the development of evidence-based guidelines for the prevention and treatment of IDH, as well as prevented accurate estimation of the population burden of IDH and patient risk assessment. Most existing IDH definitions are comprised of one or more of the following components: (1) intradialytic BP criteria (requisite BP declines or minimum BP thresholds), (2) the provision of interventions aimed at restoring effective arterial volume, and/or (3) patient-reported symptoms. Remarkably, there are insufficient data to inform IDH definition construction, and it remains unknown if a single, universal definition can adequately capture the condition across patient subgroups, and in clinical and research settings.
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Affiliation(s)
- Magdalene M. Assimon
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Jennifer E. Flythe
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
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18
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Ibarra-Sifuentes HR, Del Cueto-Aguilera Á, Gallegos-Arguijo DA, Castillo-Torres SA, Vera-Pineda R, Martínez-Granados RJ, Atilano-Díaz A, Cuellar-Monterrubio JE, Pezina-Cantú CO, Martínez-Guevara EDJ, Ortiz-Treviño JF, Delgado-García GR, Martínez-Jiménez JG, Cruz-Valdez J, Sánchez-Martínez C. Levocarnitine Decreases Intradialytic Hypotension Episodes: A Randomized Controlled Trial. Ther Apher Dial 2017; 21:459-464. [PMID: 28805348 DOI: 10.1111/1744-9987.12553] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/01/2017] [Accepted: 04/13/2017] [Indexed: 11/28/2022]
Abstract
Intradialytic hypotension is common complication in stage 5 chronic kidney disease patients on hemodialysis. Incidence ranges from 15 to 30%. These patients have levocarnitine deficiency. A randomized, placebo-controlled quadruple-blinded trial was designed to demonstrate the levocarnitine efficiency on intradialytic hypotension prevention. Patients were randomized into four groups, to receive levocarnitine or placebo. During the intervention period, levocarnitine and placebo was administered 0 and 30 min before each hemodialysis session, respectively. During the trial, 33 patients received 1188 hemodialysis sessions. We identified 239 (21.3%) intradialytic hypotension episodes. The intradialytic hypotension episodes were less frequent in the levocarnitine group (9.3%, 60 IH events) (P < 0.001). Hemodialysis is frequently perplexed by intradialytic hypotension episodes. Levocarnitine supplementation before each hemodialysis session efficiently diminishes the intradialytic hypotension episodes. This is a new application method that must be considered and explored.
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Affiliation(s)
- Héctor Raúl Ibarra-Sifuentes
- Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico.,Nephrology, Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico
| | - Ángel Del Cueto-Aguilera
- Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico
| | | | | | - Raymundo Vera-Pineda
- Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico
| | | | - Alexandro Atilano-Díaz
- Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico
| | | | | | | | | | | | - José Guadalupe Martínez-Jiménez
- Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico.,Nephrology, Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico
| | - Jesús Cruz-Valdez
- Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico.,Nephrology, Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico
| | - Concepción Sánchez-Martínez
- Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico.,Nephrology, Department of Internal Medicine, Autonomous University of Nuevo León, University Hospital, Mexico
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19
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Veenstra G, Pranskunas A, Skarupskiene I, Pilvinis V, Hemmelder MH, Ince C, Boerma EC. Ultrafiltration rate is an important determinant of microcirculatory alterations during chronic renal replacement therapy. BMC Nephrol 2017; 18:71. [PMID: 28219329 PMCID: PMC5319109 DOI: 10.1186/s12882-017-0483-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 02/09/2017] [Indexed: 02/05/2023] Open
Abstract
Background Hemodialysis (HD) with ultrafiltration (UF) in chronic renal replacement therapy is associated with hemodynamic instability, morbidity and mortality. Sublingual Sidestream Dark Field (SDF) imaging during HD revealed reductions in microcirculatory blood flow (MFI). This study aims to determine underlying mechanisms. Methods The study was performed in the Medical Centre Leeuwarden and the Lithuanian University of Health Sciences. Patients underwent 4-h HD session with linear UF. Nine patients were subject to combinations of HD and UF: 4 h of HD followed by 1 h isolated UF and 4 h HD with blood-volume-monitoring based UF. Primary endpoint: difference in MFI before and after intervention. During all sessions monitoring included blood pressure, heartrate and SDF-imaging. Trial registration number: NCT01396980. Results Baseline characteristics were not different between the two centres as within the HD/UF modalities. MFI was not different before and after HD with UF. Total UF did not differ between modalities. Median MFI decreased significantly during isolated UF [2.8 (2.5–2.9) to 2.5 (2.2–2.8), p = 0.03]. Baseline MFI of each UF session was correlated with MFI after the intervention (rs = 0.52, p = 0.006). Conclusion During HD with UF or isolated HD we observed no changes in MFI. This indicates that non-flow mediated mechanisms are of unimportance. During isolated UF we observed a reduction in MFI in conjunction with a negative intravascular fluid balance. The correlation between MFI before and after intervention suggests that volume status at baseline is a factor in microvascular alterations. In conclusion we observed a significant decrease of sublingual MFI, related to UF rate during chronic renal replacement therapy.
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Affiliation(s)
- Gerke Veenstra
- Medical Center Leeuwarden, P.O. Box 888, Leeuwarden, 8934 AD, The Netherlands. .,Translational Physiology, Academic Medical Center, Amsterdam, The Netherlands. .,Erasmus MC University Hospital Rotterdam, Rotterdam, The Netherlands.
| | | | | | - Vidas Pilvinis
- Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Marc H Hemmelder
- Medical Center Leeuwarden, P.O. Box 888, Leeuwarden, 8934 AD, The Netherlands
| | - Can Ince
- Translational Physiology, Academic Medical Center, Amsterdam, The Netherlands.,Erasmus MC University Hospital Rotterdam, Rotterdam, The Netherlands
| | - E Christiaan Boerma
- Medical Center Leeuwarden, P.O. Box 888, Leeuwarden, 8934 AD, The Netherlands
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20
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Berman N, Reid MC, Teresi J, Eimicke JP, Adelman R. More with Less: A Trial of Reduced-Intensity Treatment in Transplant-Ineligible Hemodialysis Patients. J Palliat Med 2016; 19:503-8. [PMID: 27139523 DOI: 10.1089/jpm.2015.0338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND An increasing proportion of hemodialysis patients are ineligible for transplant. Often these patients are elderly, with multiple comorbidities and decreased functional status. Such patients may benefit from modified treatment goals to reduce symptom burden. OBJECTIVE To demonstrate the feasibility of a trial of reduced-intensity treatment in nontransplantable patients with end-stage renal disease (ESRD). STUDY DESIGN A 6-week study randomized patients to a reduced-intensity intervention versus usual care. Intervention subjects were treated with liberalized goals for serum phosphorus and parathyroid hormone (PTH) as well as predialysis blood pressure in comparison with usual care subjects. Outcomes included assessed feasibility of recruitment, randomization, and data collection. SETTING AND POPULATION Sixteen transplant-ineligible hemodialysis patients were recruited from two urban units. MEASUREMENTS Blood pressure was recorded weekly, while serum PTH and phosphorus were assessed every 10 days. A quality-of-life measure was administered before and after the trial. RESULTS Of 300 patients, 51 were eligible and 16 consented. All were randomized and completed the trial. Patients in the intervention group received significantly lower doses of phosphorus binders and vitamin D analogues, and were less likely to have their dry weight reduced. All patient surveys were completed. CONCLUSIONS High-risk hemodialysis patients may benefit from liberalized treatment guidelines but larger studies are necessary.
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Affiliation(s)
- Nathaniel Berman
- 1 Division of Nephrology and Hypertension, Weill Cornell Medical College , New York, New York.,2 The Rogosin Institute , New York, New York
| | - M Carrington Reid
- 3 Division of Geriatrics and Palliative Care, Weill Cornell Medical College , New York, New York
| | - Jeanne Teresi
- 4 Research Division, Hebrew Home at Riverdale, RiverSpring Health , Bronx, New York.,5 Columbia University Stroud Center at New York State Psychiatric Institute , New York, New York
| | - Joseph P Eimicke
- 3 Division of Geriatrics and Palliative Care, Weill Cornell Medical College , New York, New York.,4 Research Division, Hebrew Home at Riverdale, RiverSpring Health , Bronx, New York
| | - Ronald Adelman
- 3 Division of Geriatrics and Palliative Care, Weill Cornell Medical College , New York, New York
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21
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Koda Y, Aoike I, Hasegawa S, Osawa Y, Nakagawa Y, Iwabuchi F, Iwahashi C, Sugimoto T, Kikutani T. Feasibility of intermittent back-filtrate infusion hemodiafiltration to reduce intradialytic hypotension in patients with cardiovascular instability: a pilot study. Clin Exp Nephrol 2016; 21:324-332. [PMID: 27125432 PMCID: PMC5388713 DOI: 10.1007/s10157-016-1270-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 04/11/2016] [Indexed: 11/22/2022]
Abstract
Background Intradialytic hypotension (IDH) is one of the major problems in performing safe hemodialysis (HD). As blood volume depletion by fluid removal is a major cause of hypotension, careful regulation of blood volume change is fundamental. This study examined the effect of intermittent back-filtrate infusion hemodiafiltration (I-HDF), which modifies infusion and ultrafiltration pattern. Methods Purified on-line quality dialysate was intermittently infused by back filtration through the dialysis membrane with a programmed dialysis machine. A bolus of 200 ml of dialysate was infused at 30 min intervals. The volume infused was offset by increasing the fluid removal over the next 30 min by an equivalent amount. Seventy-seven hypotension-prone patients with over 20-mmHg reduction of systolic blood pressure during dialysis or intervention-requirement of more than once a week were included in the crossover study of 4 weeks duration for each modality. In a total of 1632 sessions, the frequency of interventions, the blood pressure, and the pulse rate were documented. Results During I-HDF, interventions for symptomatic hypotension were reduced significantly from 4.5 to 3.0 (per person-month, median) and intradialytic systolic blood pressure was 4 mmHg higher on average. The heart rate was lower during I-HDF than HD in the later session. Older patients and those with greater interdialytic weight gain responded to I-HDF. Conclusions I-HDF could reduce interventions for IDH. It is accompanied with the increased intradialytic blood pressure and the less tachycardia, suggesting less sympathetic stimulation occurs. Thus, I-HDF could be beneficial for some hypotension-prone patients. UMIN registration number 000013816.
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Affiliation(s)
- Yutaka Koda
- Koda Medical and Dialysis Clinic, 3748 Yoshida, Tsubame, Niigata, 959-0264, Japan.
| | - Ikuo Aoike
- Koyo Medical Clinic, Konan-ku, Niigata, 950-0121, Japan
| | - Shin Hasegawa
- Kashiwazaki General Medical Center, Kashiwazaki, Niigata, 945-8535, Japan
| | - Yutaka Osawa
- Niigata Rinko Hospital, Higashi-ku, Niigata, 950-8725, Japan
| | - Yoichi Nakagawa
- Nakagawa Medical Clinic, Utsunomiya, Tochigi, 321-0157, Japan
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22
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Abstract
BACKGROUND Frequent blood pressure (BP) measurements are necessary to ensure patient safety during hemodialysis treatments. Intradialytic BPs are not optimal tools for hypertension diagnosis and cardiovascular risk stratification, but they do have critical clinical and prognostic significance. We present evidence associating intradialytic BP phenomena including fall, rise and variability with adverse clinical outcomes and review related pathophysiologic mechanisms and potential management strategies. SUMMARY Observational studies demonstrate associations between intradialytic hypotension, hypertension and BP variability and mortality. Lack of consensus regarding diagnostic criteria has hampered data synthesis, and prospective studies investigating optimal management strategies for BP phenomena are lacking. Mechanistic data suggest that cardiac, gut, kidney and brain ischemia may lie on the causal pathway between intradialytic hypotension and mortality, and endothelial cell dysfunction, among other factors, may be an important mediator of intradialytic hypertension and adverse outcomes. These plausible pathophysiologic links present potential therapeutic targets for future inquiry. The phenomenon of intradialytic BP variability has not been adequately studied, and practical clinical measures and treatment strategies are lacking. KEY MESSAGES Intradialytic BP phenomena have important prognostic bearing. Clinical practice guidelines for both intradialytic hypotension and hypertension exist, but their underlying evidence is weak overall. Further research is needed to develop consensus diagnostic criteria for intradialytic hypotension, hypertension and BP variability and to elucidate optimal treatment and prevention strategies for each BP manifestation.
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Affiliation(s)
- Magdalene M. Assimon
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Jennifer E. Flythe
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
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