Abstract
This study aimed to identify whether a new method using heart rate variability (HRV) could predict intradialytic hypotension (IDH) for one month in advance for patients undergoing prevalent hemodialysis. A total 71 patients were enrolled, and baseline clinical characteristics and laboratory results were collected when HRV was measured, then, the frequency of IDH was collected during the observation period. HRV parameters included heart rate, R-R interval, the standard deviation of N-N interval, the square root of the mean squared differences of successive NN intervals, very low frequency, low frequency, high frequency, total power, and low frequency/high frequency ratio. During the one-month observation period, 28 patients experienced 85 cases of IDH (10.0% of a total 852 dialysis sessions). Among the clinical and laboratory parameters, ultrafiltration rate, prior history of diabetes, coronary artery disease, or congestive heart failure, age, intact parathyroid hormone level, and history of antihypertensive drug use were integrated into the multivariate model, referred to as a basic model, which showed significant ability to predict IDH (the area-under-curve [AUC], 0.726; p = 0.002). In HRV parameters, changes between the early and middle phases of hemodialysis (referred to Δ) were identified as significant independent variables. New models were built from the combination of Δ values with the basic model. Among them, a model with the highest AUC value (AUC, 804; p < 0.001) was compared to the basic model and demonstrated improved performance when HRV parameters were used (p = 0.049). Based on our results, it is possible that future IDH might be predicted more accurately using HRV.
Highlights
Intradialytic hypotension (IDH), a very challenging complication in patients on hemodialysis, is associated with increased mortality[1,2], cerebral ischemia[3], vascular access thrombosis[4], cardiovascular events[5], and hospitalizations[6]
A study to evaluate Heart rate variability (HRV) during hemodialysis showed that the sympathetic response is activated and increases during hemodialysis; in patients prone to intradialytic hypotension (IDH), such activation is impaired in the late phase of dialysis, contributing to development of IDH15
For the patients in the IDH group, the post-dialysis systolic blood pressure was significantly lower than the pre-dialysis systolic blood pressure (124 ± 23 vs. 141 ± 23, p < 0.001), but this result was not observed for the non-IDH group (141 ± 21 vs. 136 ± 17, p = 0.323)
Summary
Intradialytic hypotension (IDH), a very challenging complication in patients on hemodialysis, is associated with increased mortality[1,2], cerebral ischemia[3], vascular access thrombosis[4], cardiovascular events[5], and hospitalizations[6]. Kersh et al showed that IDH developed because of autonomic nervous insufficiency. Converse et al reported that hemodialysis-induced hypotension is caused by autonomic dysfunction, leading to an inadequate sympathetic response to hypovolemia developed during hemodialysis[12]. Heart rate variability (HRV) provides a non-invasive and reliable way to measure autonomic dysfunction[13]. A study to evaluate HRV during hemodialysis showed that the sympathetic response is activated and increases during hemodialysis; in patients prone to IDH, such activation is impaired in the late phase of dialysis, contributing to development of IDH15. Another study that measured HRV during hemodialysis showed that sympathetic nervous activity increases; the increased tone of the sympathetic nervous system suddenly falls when symptomatic hypotension develops (“Bezold-Jarisch reflex”)[16]. We hypothesized that HRV is a reliable way to predict the development of future IDH
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