Abstract
Intradialytic hypotension can lead to superimposed organ hypoperfusion and ultimately worsens long-term kidney outcomes in critically ill patients requiring kidney replacement therapy. Acetate-free biofiltration (AFB), an alternative technique to bicarbonate-based hemodialysis (B-IHD) that does not require dialysate acidification, may improve hemodynamic and metabolic tolerance of dialysis. In this study, we included 49 mechanically ventilated patients requiring 4 h dialysis (AFB sessions n = 66; B-IHD sessions n = 62). Whereas more AFB sessions were performed in patients at risk of hemodynamic intolerance, episodes of intradialytic hypotension were significantly less frequent during AFB compared to B-IHD, whatever the classification used (decrease in mean blood pressure ≥ 10 mmHg; systolic blood pressure decrease >20 mmHg or absolute value below 95 mmHg) and after adjustment on the use of vasoactive agent. Diastolic blood pressure readily increased throughout the dialysis session. The use of a bicarbonate zero dialysate allowed the removal of 113 ± 25 mL/min of CO2 by the hemofilter. After bicarbonate reinjection, the global CO2 load induced by AFB was +25 ± 6 compared to +80 ± 12 mL/min with B-IHD (p = 0.0002). Thus, notwithstanding the non-controlled design of this study, hemodynamic tolerance of AFB appears superior to B-IHD in mechanically ventilated patients. Its use as a platform for CO2 removal also warrants further research.
Highlights
Because intradialytic hypotension can lead to superimposed organ hypoperfusion and mitigate long-term kidney outcomes after acute kidney injury, it remains a concern in critically ill patients requiring kidney replacement therapy
We showed that hemodynamic tolerance was better in mechanically ventilated critically ill patients receiving Acetate-free biofiltration (AFB) compared to conventional B-intermittent hemodialysis (IHD), despite higher vasoactive support at the start of AFB sessions
Because other dialysis and patient characteristics were balanced between the two groups or in favor of bicarbonate-rich dialysate (B-IHD), the discrepancies between the contents of the blood that returns to the patients during AFB and B-IHD probably account for the divergent hemodynamic tolerance
Summary
Because intradialytic hypotension can lead to superimposed organ hypoperfusion and mitigate long-term kidney outcomes after acute kidney injury, it remains a concern in critically ill patients requiring kidney replacement therapy. Usual IHD techniques use bicarbonate-rich dialysate (B-IHD) but require acidification of the dialysate with acetate, citrate or hydrochloric acid to avoid calcium carbonatation within the dialysis filter. Beyond the direct effect of acetate on cardiac contractility and vascular tone, dialysate acidification by itself may lead to systemic vascular effects, including on the pulmonary vascular bed, due to the release of high amounts of carbon dioxide in the blood outflow, whatever the acid used [4]. There is an unmet need to optimize tolerance of IHD, especially in critically ill patients, and modulating dialysate may reduce the rate of intradialytic hypotension
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