Dialysate Temperature Research Articles

Centre-level fluid management practices in the BISTRO trial and their lack of association with participant fluid status and blood pressure in non-anuric haemodialysis patients.

Fluid assessment and management is a key aspect of good dialysis care and is affected by patient-level characteristics and potentially centre-level practices. In this secondary analysis of the BISTRO trial we wished to establish whether centre-level practices with the potential to affect fluid status were stable over the course of the trial and explore if they had any residual associations with participant's fluid status. Two surveys (S) of fluid management practices were conducted in 32 participating centres during the trial, (S1: 2017-18 and S2: 2021-22). Domains interrogated included: dialysate sodium concentration, (D-[Na+]), fluid and salt intake, residual kidney function, use of diuretics, incremental start, approaches to fluid assessment, management and dialysate temperature, (D-oC). Associations of these practices with the closeness of the participant's post-dialysis target weight to their normally hydrated weight, pre- and post-dialysis systolic (SBP) and diastolic blood pressure, (DBP), were analysed using intra-class correlations and multilevel modelling with adjustment for visit, age, sex and comorbidity burden. Variations in centre practices were reported but did not change during the trial, apart from some relaxation in salt and fluid restriction in S2. For our measures of fluid status, measured 2501 times in 439 non-anuric incident haemodialysis patients, centre-level intraclass correlations were extremely low, whereas patient-level correlations ranged between 0.12 and 0.47, strongest for pre- and post-dialysis-SBP, less so for post-dialysis-DBP. Multi-level analysis found no associations between D-[Na+], or assessment methods of fluid status. In S2, one centre, routinely using a D-Co of 35°C had more divergence between the target and normally hydrated weight, but this was not observed in S1, and no other associations were found. Centre-level fluid management practices were stable over the course of the BISTRO trial, and in contrast to patient-level factors, no centre-level associations were detected with fluid status or blood pressure. This may be because the trial imposed a standardised approach to fluid assessment in all trial participants who at least initially had residual kidney function, potentially over-riding the effects of other centre practices. Survey responses revealed substantial scope for developing and evaluating standardised protocols to optimise fluid management.

Effect of different dialysate temperatures on post dialysis fatigue in patients undergoing haemodialysis: a quasi-experimental study.

To compare the effects of warm and cold dialysate solutions on the duration of post-dialysis fatigue in patients undergoing maintenance haemodialysis. The quasi-experimental study was conducted at the Department of Nephrology, Pak Emirates Military Hospital, Rawalpindi, Pakistan, from May 9 to September 10, 2023, and comprised adult patients of either gender undergoing maintenance haemodialysis for a minimum of 3 months. The patient initially underwent haemodialysis with a dialysate temperature of 36°C for 2 weeks. During the subsequent washout period of one week when the dialysate temperature was not monitored, they underwent haemodialysis with a dialysate temperature of 37°C for another 2 weeks. Blood pressure was monitored every 30 minutes to record any hypotensive episodes. Patients were asked if they felt fatigued after the last haemodialysis session, and the duration was noted down. Data was analysed using SPSS 24. Of the 92 patients with mean age 49.1±16.1 years, 57(62%) were males. Post-dialysis fatigue was seen in 67(72.8%) and 75(81.5%) patients with dialysate temperatures at 36°C and 37°C, respectively (p<0.001). The duration of post-dialysis fatigue was also significantly longer at dialysate temperatures 37°C p<0.001). There was no significant difference in the proportion of hypotensive episodes in the two groups (p=0.445). Dialysate temperature 36°C was found to be associated with less frequent and shorter duration of postdialysis fatigue compared to dialysate temperature 37°C.

Recurrent localized fever caused by cryoglobulinemic vasculitis following hemodialysis: A case report.

Post-dialysis fever is commonly reported in patients undergoing hemodialysis (HD). However, it is often challenging to identify the underlying cause owing to the wide variety of potential factors that can lead to fever. In this case, a 66-year-old Japanese man experienced recurrent fever after HD treatment. Initially, antibiotics were prescribed to treat pneumonia, but it was later discovered that the pneumonia was an alveolar hemorrhage caused by cryoglobulinemic vasculitis. It is believed that cryoglobulin was sensitized by cold exposure owing to the dialysate temperature, which resulted in fever being experienced only after HD. Although treatment for vasculitis required prednisolone and rituximab, simple plasma exchange and a dialysate temperature of 37.5°C dramatically suppressed the occurrence of post-dialysis fever. Cryoglobulinemia should be considered as a potential cause of fever, as it may be a common occurrence in patients undergoing HD and could be overlooked as a possible cause of localized fever following HD treatment.

Efficacy of sutimlimab for cold agglutinin disease in a patient on chronic hemodialysis.

Reports of cold agglutinin disease (CAD), an autoimmune hemolytic anemia, in dialysis patients are limited. Recently, sutimlimab for CAD was covered by insurance. Herein, we report a case in which sutimlimab was effective in the treatment of CAD in a patient undergoing hemodialysis (HD). The patient was a 73year-old Japanese man with an 11year history of HD for diabetic nephropathy. He was admitted to our hospital for examination and treatment of erythropoiesis-stimulating agent (ESA)-induced hyporesponsive anemia and fatigue, which was present in the previous year October to March when temperatures were cooler. The patient was diagnosed with hemolytic anemia based on decreased hemoglobin levels, elevated reticulocyte count, elevated lactate dehydrogenase levels, and decreased haptoglobin levels. Furthermore, he was diagnosed with CAD based on a positive direct antiglobulin test for C3 and cold agglutinin tests. The patient did not respond well to an elevated dialysate temperature or rituximab therapy. After initiating sutimlimab treatment, an increase in the hemoglobin level was observed despite a decrease in temperature, and his fatigue disappeared. Anemia in hemodialysis patients is generally renal; however, some ESA resistance exists, which may be due to hemolytic anemia. In this case, the use of sutimlimab was effective in controlling hemolytic anemia due to CAD.

#2570 Non-invasive blood pressure monitoring in dialysis patients using pulse wave velocity

Abstract Background and Aims Dialysis patients are at high risk of circulatory dysregulation and hypotension during treatment. Intradialytic hypotension (IDH) is a potentially life-threatening complication. The main causes are high ultrafiltration volumes and high ultrafiltration rates when patients tend to gain a lot of weight between dialysis treatments. A lack of patient compliance with regard to drinking volumes and a lack of residual diuresis are risk factors for this. Close circulatory monitoring and therapy settings to avoid absolute or relatively high UF rates to prevent IDH are frequently used. These are primarily the frequent non-invasive measurement of blood pressure using cuffs, the measurement of relative blood volume and the adjustment of ultrafiltration rates to these values. Prophylactically, the dialysis time can be extended, ultrafiltration profiles or ultrafiltration breaks can be planned, the dialysate temperature can be lowered and the composition of the dialysate can be adjusted. Despite all attempts, however, the incidence of IDH in everyday clinical practice is too high. The non-invasive measurements with cuffs are not carried out frequently enough, the measurement of the relative blood volume only covers a partial range, sudden changes in vascular tension or cardiac output are not recorded. Method The pulse wave velocity (PWV) is a well-known parameter for describing the propagation of the pressure wave after ejection of the heart beat volume in the arteries. The PWV is dependent on blood pressure, vessel wall tension and cardiac output. Changes in blood pressure can therefore be recognised by measuring the PWV. With the help of a measuring device (PESAS) for the ECG signal and peripheral pulse plethysmography, PWV can be measured non-invasively, continuously, for every heartbeat and, above all, hardly noticed by the patient. The PESAS allows the time-synchronised measurement of ECG and peripheral plethysmography curves and thus the determination of PWV. It is an experimental device. We would like to present a study showing the use of a measuring device (PESAS) in 15 prevalent dialysis patients for the detection of IDH. All study participants were examined during 3 dialysis treatments. Results The measurement of PWV in chronic dialysis patients during treatment is technically feasible. The measurement is tolerated by the patients. Changes in PWV could be detected in the patients during the course of dialysis; these were also dependent on the ultrafiltration rates. Individual patient reactions to volume withdrawal varied, with both increases and decreases in PWV being demonstrated. An acute change in PWV was usually associated with a drop in blood pressure. Continuous measurement allowed IDH events to be detected earlier than intermittent blood pressure measurement with cuffs. Sudden drops in blood pressure could be detected better and earlier with the PESAS system than by measuring the relative blood volume. Conclusion The PESAS system is suitable for monitoring dialysis patients to prevent IDH. Further adjustments and optimisation of the evaluation algorithms are necessary.

A Pilot Study on the Safety and Adequacy of a Novel Ecofriendly Hemodialysis Prescription–Green Nephrology

Hemodialysis (HD) units require large quantities of water. To reduce water consumption without compromising the adequacy and safety of dialysis, we studied a novel HD prescription with high temperature and low flow dialysate. This was a single-center nonrandomized open-label cross-over pilot trial in patients with end-stage kidney disease on maintenance HD. Each participant was subjected to 3 different dialysis prescriptions for 1 month each as follows: (i) normal temperature with normal flow dialysate (NTNF prescription), (ii) high temperature with normal flow dialysate (HTNF prescription), and (iii) high temperature with low flow dialysate (HTLF prescription). The primary outcome, assessed at the end of each dialysis session, was the delivery of "adequate" dialysis, as defined by a single-pool Kt/V (spKt/V)≥1.2. Outcomes were evaluated by comparing the NTNF and HTLF prescriptions. A total of 863 sessions of HD were performed in 30 patients over 3 months, with 287 to 288 sessions in each of the 3 dialysis prescriptions. The primary outcome was not significantly different between the NTNF prescription (202 sessions [70.14%]) and the HTLF prescription (198 sessions [68.75%]) (odds ratio, 1.07; 95% confidence interval, 0.75 to 1.52; P= 0.45). The mean spKt/V and urea reduction ratio (URR) were not significantly different. Clinically evident hemodynamic instability occurred in only 1 dialysis session in the HTNF prescription. Increasing dialysate temperature while reducing dialysate flow rate (QD) can be used as a water conservation strategy without compromising the adequacy and safety of dialysis in young and hemodynamically stable patients. Reducing the QD from 500 ml/min to 300 ml/min reduces water consumption by 40%.

The Acute, Combined, and Separate Effects of Cold Hemodialysis and Intradialytic Exercise in Insulin Sensitivity and Glucose Disposal.

Hemodialysis (HD) patients suffer from multiple health problems, including severe insulin resistance. Both cold dialysis and intradialytic exercise training could elicit health benefits; however, it is still unknown whether the combination of those two approaches could enhance overall health. The current study aimed to evaluate the separate and combined acute effects of a single session of cold dialysis and intradialytic exercise in parameters related to insulin sensitivity and glucose disposal. Ten HD patients (57.2 ± 14.9 years) participated in the study. Each patient participated in four different scenarios during HD: a) typical dialysis with dialysate temperature at 37°C (TD), b) cold dialysis with dialysate temperature at 35°C, c) typical HD combined with a single exercise bout, d) cold dialysis combined with a single exercise bout. Glucose disposal and insulin resistance were assessed immediately after the end of the HD session. None of the examined parameters significantly differed between the four scenarios ( p > 0.05). However, slight numerical changes and moderate to high effect size ( d : 0.50-0.85) were observed between TD versus cold dialysis and TD versus TD + exercise in glucose and insulin disposal rates. A single session of cold and TD with intradialytic exercise may provide an "acute" time-efficient stimulus for consecutively improving glucose disposal and insulin sensitivity.

Nephrology: what's new in 2023

Molecules such as sparsentan and budesonide look promising to treat proteinuric IGA nephropathy. SLGT2 inhibitors have a prominent place in nephroprotection and could be used in the treatment of acute kidney injury due to heart failure as well. High volume hemodiafiltration compared to hemodialysis improves survival in dialysis patients. Lessening dialysate temperature does not improve hemodynamic stability during the dialysis session. Sodium bicarbonate does not seem to protect renal function in renal transplant patients. SGLT2 inhibitors may have a beneficial effect in these patients in terms of nephroprotection.

Arduino microcontroller based real-time monitoring of haemodialysis process for patients with kidney disease

The efficient and precise monitoring of the haemodialysis process is critical for the well-being of patients suffering from end-stage renal disease (ESRD). In this work, a comprehensive study on the utilization of Arduino microcontroller-based systems for real-time monitoring, data acquisition and control of the haemodialysis process is presented. Arduino instrumentation unit was developed for an in vitro Haemodialysis (HD) system using Atmega 328 and Arduino nano microcontrollers. Haemodialysis process was conducted using in vitro haemodialysis system. Temperature probes (model DS18B20), conductivity probes (model EC-PPM-TDS) and weight sensor (load cell type HX711, 10 kg max stain gauge type) were used for real-time measuring and monitoring blood and dialysate temperatures, conductivities, and blood weight respectively. Simulink interface embedded in MATLAB software R.2019 was used as microcontroller software interface. In vitro HD result of the real-time monitoring indicated that initial and final measurement for blood temperatures gave 32.8 – 36.5 °C at set dialysate temperature 37 °C respectively, blood and dialysate conductivity 2 - 3.5 mS/cm and intradialytic blood weight 187.5 g – 147.5 g. This paper offers valuable insights into the implementation of Arduino microcontrollers for real-time monitoring of the haemodialysis process, with a strong emphasis on patient safety, data generation and data security. The research presented contributes to the advancement of technology in the field of nephrology and has the potential to significantly impact the quality of life for ESRD patients undergoing haemodialysis.

Could cooling dialysate improve inflammatory and nutritional status of hemodialysis patients?

BackgroundIt has been shown that dialysate cooling (lowering the dialysate temperature to 0.5 °C below central body temperature) reduces the incidence of intradialytic hypotension. Other influences on hemodialysis patients, however, have not been adequately investigated. The purpose of this study was to determine the impact of individualized dialysate cooling on nutritional and inflammatory parameters in chronic hemodialysis (HD) patients.MethodsSeventy HD patients were separated into two groups: group A: (control group) standard dialysate temperature was 37 °C, and group B: (intervention group) dialysate temperature was 0.5 °C below core body temperature. In addition to routine laboratory tests, blood pressure, anthropometric measurements, inflammatory markers, and the malnutrition inflammation score (MIS) were calculated.ResultsAfter six months of dialysate cooling, intradialytic hypotension episodes were much less prevalent in the intervention group (p = 0.001). Serum ferritin, transferrin saturation (TSAT), high sensitive C-reactive protein (HS-CRP), and Interleukin-6 (IL-6) reduced following dialysate cooling, whereas serum albumin rose. In the control group, IL-6 dropped but serum ferritin, TSAT, albumin, and HS-CRP rose. In both groups, hemoglobin levels dropped, and erythrocyte sedimentation rate (ESR) rose, both groups’ midarm muscle circumference and MIS worsened.ConclusionCold dialysate decreased intradialytic hypotension with no significant improvement of the nutritional and inflammatory surrogates. However, more studies including larger number of patients with longer duration of follow up are required to adequately assess its effect on inflammation and nutrition in chronic hemodialysis patients.

Cooler dialysate temperature for the prevention of intradialytic hypotension: Is it time for a shift in our practice?

Cooler dialysate temperature for the prevention of intradialytic hypotension: Is it time for a shift in our practice?

Study The Effect of Na concentration, Dialysate Temperature on Intra Dialytic Hypotension on Regular Hemodialysis Patients

Study The Effect of Na concentration, Dialysate Temperature on Intra Dialytic Hypotension on Regular Hemodialysis Patients

Physical intradialytic patient-reported outcome measures in haemodialysis and haemodiafiltration: A cross-over study.

Standard haemodialysis (sHD) is associated with a poor survival and marked adverse intradialytic patient-reported outcome measures (ID-PROMs). Whereas physical ID-PROMs (PID-PROMs) are alleviated by cool dialysate (cHD), survival is prolonged by haemodiafiltration (HDF). So far, PID-PROMs are not prospectively compared between HD and HDF. To assess whether PID-PROMs and thermal perception differ between sHD, cHD, low volume HDF (lvHDF) and high volume HDF (hvHDF), 40 patients were cross-over randomized to each modality for 2 weeks. Dialysate temperature (Td ) was 36.5°C, except in cHD (Td 35.5°C). Target convection volumes were 15 L in lvHDF and ≥ 23 L in hvHDF. PID-PROMs were evaluated with a modified Dialysis Symptom Index (mDSI) and thermal perception with the Visual Analogue Scale Thermal Perception (VAS-TP). Tb and room temperature were measured as well. Except for the item 'feeling cold' during cHD (p=.01), PID-PROMs did not differ between modalities, but varied markedly between patients (11/13 items, p < .05). Tb increased in sHD, lvHDF, and hvHDF (+0.30, 0.35, 0.38°C, respectively, all p < .0005), but remained stable in cHD (+0.04°C, p=.43). Thermal perception remained unaltered in sHD and both HDF modalities, but shifted towards cold in cHD (p=.007). (1) PID-PROMs did not differ between modalities, but varied markedly between patients. Hence, PID-PROMs are largely patient-dependent. (2) While Tb increased in sHD, lvHDF and hvHDF, thermal perception did not change. Yet, whereas Tb remained unaltered in cHD, cold perception emerged. Hence, as for bothersome cold sensations, cHD should be avoided in perceptive individuals.

Analysis of Dialysate pH and Temperature Stability on Hemodialysis Machines Using Internet of Thing Technology

Therapy for kidney replacement with hemodialysis is a treatment that is carried out in patients with Chronic Kidney Failure to survive. The purpose of this study was to determine the stability of the dialysate fluid in the hemodialysis machine by measuring the temperature using the DS18B20 sensor and measuring the dialysate pH using the 4502C sensor on pre and post-hemodialysis. The research method and the manufacture of this module use a pre-experimental research design with the type of research "one group posttest design" the independent variables are the pH value and Dialysate Temperature, the dependent variable is the pH and Temperature Sensor, the control variable is the Traceable Tool. This research made a module using an Esp32 microcontroller system with an LCD that can be monitored with Android via the Internet of Things (IoT) system. 03 and the comparison of the results of the dialysate temperature values ​​at the time of pre and post-obtained the maximum measurement error of 0.2%. From the measurement and analysis data, it can be concluded that there is no effect of pH and temperature values ​​during pre and post hemodialysis.

Effectiveness of Cold Hemodialysis (HD) for the Prevention of HD Hypotension and Mortality in the General HD Population.

Cold hemodialysis (HD) prevented intra dialysis hypotension (IDH) in small, short term, randomized trials in selected patients with IDH. Whether this treatments prevents IDH and mortality in the HD population at large is unknown. We investigated the relationship between dialysate temperature and the risk of IDH, i.e. nadir BP <90mmHg, (GEE model) and all cause mortality (Cox's regression) in an incident cohort of hemodialysis patients (n=8071). To control for confounding by bias by indication and other factors we applied instrumental variables adjusting for case mix at facility level. The twenty-seven % of patients in the study cohort were systematically treated with a dialysate temperature≤35.5°. Over a median follow-up of 13.6 months (IQR: 5.2-26.1 months), a 0.5°C reduction of the dialysate temperature was associated with a small (-2.4%) reduction of the risk of IDH [OR: 0.976, 95% CI: 0.957-0.995, P=0.013]. In case-mix, facility level adjusted analysis, the association became much stronger [OR: 0.67, 95% CI: 0.63-0.72, Risk reduction=33%), P<0.001]. In contrast, colder dialysate temperature had no effect on mortality both in the unadjusted [hazard ratio (HR) (0.5°C decrease): 1.074, 95%: 0.972-1.187, P=0.16] and case-mix adjusted analysis at facility level [HR: 1.01, 95% CI: 0.88-1.16, P=0.84]. Similar results were registered in additional analyses by instrumental variables applying the median dialysate temperature or the facility percentage of patients prescribed a dialysate temperature<36°C. Further analyses restricted to patients with recurrent IDH fully confirmed these findings. Cold HD was associated with IDH in the hemodialysis population but had no association with all-cause mortality.

Personalised cooler dialysate for patients receiving maintenance haemodialysis (MyTEMP): a pragmatic, cluster-randomised trial

Haemodialysis centres have conventionally provided maintenance haemodialysis using a standard dialysate temperature (eg, 36·5°C) for all patients. Many centres now use cooler dialysate (eg, 36·0°C or lower) for potential cardiovascular benefits. We aimed to assess whether personalised cooler dialysate, implemented as centre-wide policy, reduced the risk of cardiovascular-related death or hospital admission compared with standard temperature dialysate. MyTEMP was a pragmatic, two-arm, parallel-group, registry-based, open-label, cluster-randomised, superiority trial done at haemodialysis centres in Ontario, Canada. Eligible centres provided maintenance haemodialysis to at least 15 patients a week, and the medical director of each centre had to confirm that their centre would deliver the assigned intervention. Using covariate-constrained randomisation, we allocated 84 centres (1:1) to use either personalised cooler dialysate (nurses set the dialysate temperature 0·5-0·9°C below each patient's measured pre-dialysis body temperature, with a lowest recommended dialysate temperature of 35·5°C), or standard temperature dialysate (36·5°C for all patients and treatments). Patients and health-care providers were not masked to the group assignment; however, the primary outcome was recorded in provincial databases by medical coders who were unaware of the trial or the centres' group assignment. The primary composite outcome was cardiovascular-related death or hospital admission with myocardial infarction, ischaemic stroke, or congestive heart failure during the 4-year trial period. Analysis was by intention to treat. The study is registered at ClinicalTrials.gov, NCT02628366. We assessed all of Ontario's 97 centres for inclusion into the study. Nine centres had less than 15 patients and one director requested that four of their seven centres not participate. 84 centres were recruited and on Feb 1, 2017, these centres were randomly assigned to administer personalised cooler dialysate (42 centres) or standard temperature dialysate (42 centres). The intervention period was from April 3, 2017, to March 31, 2021, and during this time the trial centres provided outpatient maintenance haemodialysis to 15 413 patients (about 4·3 million haemodialysis treatments). The mean dialysate temperature was 35·8°C in the cooler dialysate group and 36·4°C in the standard temperature group. The primary outcome occurred in 1711 (21·4%) of 8000 patients in the cooler dialysate group versus 1658 (22·4%) of 7413 patients in the standard temperature group (adjusted hazard ratio 1·00, 96% CI 0·89 to 1·11; p=0·93). The mean drop in intradialytic systolic blood pressure was 26·6 mm Hg in the cooler dialysate group and 27·1 mm Hg in the standard temperature group (mean difference -0·5 mm Hg, 99% CI -1·4 to 0·4; p=0·14). Centre-wide delivery of personalised cooler dialysate did not significantly reduce the risk of major cardiovascular events compared with standard temperature dialysate. The rising popularity of cooler dialysate is called into question by this study, and the risks and benefits of cooler dialysate in some patient populations should be clarified in future trials. Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Renal Network, Ontario Strategy for Patient-Oriented Research Support Unit, Dialysis Clinic, Inc., ICES (formerly known as the Institute for Clinical Evaluative Sciences), Lawson Health Research Institute, and Western University.

High-Volume Hemodiafiltration and Cool Hemodialysis Have a Beneficial Effect on Intradialytic Hemodynamics: A Randomized Cross-Over Trial of Four Intermittent Dialysis Strategies

IntroductionCompared to standard hemodialysis (S-HD), postdilution hemodiafiltration (HDF) has been associated with improved survival.MethodsTo assess whether intradialytic hemodynamics may play a role in this respect, 40 chronic dialysis patients were cross-over randomized to S-HD (dialysate temperature [Td] 36.5 °C), cooled HD (C-HD; Td 35.5 °C), and HDF (low-volume [LV-HDF)] and high-volume [HV-HDF], both Td 36.5 °C, convection volume 15 liters, and at least 23 liters per session, respectively), each for 2 weeks. Blood pressure (BP) was measured every 15 minutes. The primary endpoint was the number of intradialytic hypotensive (IDH) episodes per session. IDH was defined as systolic BP (SBP) less than 90 mmHg for predialysis SBP less than 160 mmHg and less than 100 mmHg for predialysis SBP greater than or equal to 160 mmHg, independent of symptoms and interventions. A post hoc analysis on early-onset IDH was performed as well. Secondary endpoints included intradialytic courses of SBP, diastolic BP (DBP) and mean arterial pressure (MAP).ResultsDuring S-HD, IDH occurred 0.68 episodes per session, which was 3.2 and 2.5 times higher than during C-HD (0.21 per session, P < 0.0005) and HV-HDF (0.27 per session, P < 0.0005), respectively. Whereas the latter 2 strategies showed similar frequencies, HV-HDF differed significantly from LV-HDF (P = 0.02). A comparable trend was observed for early-onset IDH: S-HD (0.32 per session), C-HD (0.07 per session, P < 0.0005) and HV-HDF (0.10 per session, P = 0.001). SBP, DBP, and MAP declined during S-HD (−6.8, −5.2, −5.2 mmHg per session; P = 0.004, P < 0.0005, P = 0.002 respectively), which was markedly different from C-HD (P < 0.01).ConclusionThough C-HD and HV-HDF showed the lowest IDH frequency and the best intradialytic hemodynamic stability, all parameters were most disrupted in S-HD. Therefore, the survival benefit of HV-HDF over S-HD may be partly caused by a more beneficial intradialytic BP profile.

Using the Intelligent System to Improve the Delivered Adequacy of Dialysis by Preventing Intradialytic Complications

Acute kidney failure patients while detoxificated by hemodialysis (HD) mostly or continuously faced regular problems such as low blood pressure (hypotension), muscle cramps, nausea, or vomiting. Higher intradialytic symptom leads to low-quality HD treatment. Although more known therapeutic interventions are used to relieve the HD side effects, this study was designed to investigate how intelligent systems can make highly beneficial alterations in dialysis facilities and equipment to ease intradialytic complications and help the staff deliver high-quality treatment. A search was performed among relevant research articles based on nonpharmacological intervention methods considered to prevent adverse effects of renal replacement therapy until 2020 in the PubMed databases using the terms “intradialytic complications,” “intradialytic complication interventions,” “nonpharmacological interventions,” “intradialytic exercises,” and “adequacy calculation methods.” Studies included the prevalence of intradialytic complications, different strategies with the aim of preventing complications, the outcome of intradialytic exercises on dialysis symptoms, and dialysis dose calculation methods. The results showed the incidence of hypotension varying between 5% and 30%, fatigue, muscular cramps, and vomiting as the most common complications during dialysis, which greatly affect the outcome of HD sessions. To prevent hypotension, ultrafiltration profiling, sodium modeling, low dialysate temperature, and changing the position to Trendelenburg are some strategies. Urea reduction ratio (URR), formal urea kinetic modeling (FUKM), formal single-pool urea kinetics, and online clearance monitoring (OCM) are methods for calculating the delivered dose of dialysis in which OCM is a low-cost and accessible way to monitor regularly the quality of dialysis delivered. Integration of the chair and HD machine which is in direct contact with the patient provides an intelligent system that improves the management of the dialysis session to enhance the quality of healthcare service.

MO124: Intradialytic Symptomatology is Largely Patient-Specific in both Haemodialysis and Haemodiafiltration: A Randomized Cross-Over Trial between Four Intermittent Dialysis Modalities

Abstract BACKGROUND AND AIMS Standard haemodialysis is associated with a considerable burden of intradialytic symptoms. Although haemodialysis with cool dialysate is associated with less intradialytic discomfort in general, the incidence of cold sensations increases significantly. Whether treatment with online post-dilution high-volume haemodiafiltration [target convection volume (CV) ≥23 L/session] reduces adverse intradialytic symptoms and provokes cold sensations is unknown. METHOD We performed a randomized controlled cross-over trial in 40 prevalent dialysis patients, who were subjected to two haemodialysis modalities: standard haemodialysis [sHD; dialysate temperature (Td) of 36.5°C] and cool haemodialysis (cHD; Td 35.5°C) and two haemodiafiltration modalities: low-volume haemodiafiltration (lvHDF, CV 15 L/1.73 m2/session, Td 36.5°C) and high-volume haemodiafiltration (hvHDF, CV ≥23 L/1.73 m2/session, Td 36.5°C). Every dialysis modality lasted 2 weeks. Intradialytic symptoms were evaluated after the last session of each dialysis modality, with a slightly modified Dialysis Symptom Index (mDSI). Intradialytic thermal sensations were scored on the Visual Analogue Scale Thermal Perception (VAS-TP) before and after 1 and 3 h of each treatment session. Patients were trained to use the mDSI and VAS-TP, in order to reduce incidental stress and unwanted learning responses due to the trial environment. Repeated measures analysis of variance (ANOVA) and one-way ANOVA were used to measure potential differences in intradialytic symptoms between the dialysis modalities (intraindividual differences) and to assess potential interindividual differences in intradialytic symptoms. Linear mixed models with an interaction term between time and modality were used to determine differences in rate of change of VAS-TP between the four modalities. When appropriate, stratified models were fitted subsequently. RESULTS With the exception of cold sensations during cHD (P = .01), intradialytic symptoms did not differ between modalities, but varied markedly between patients (P &amp;lt; .05 in 11/13 items, Table 1). While the VAS-TP score remained unaltered in sHD, lvHDF and hvHDF, patients felt significantly more cold sensations during cHD (P = .007)(Figure 1). Stratified models showed a decrease of 0.43 points/h on the VAS-TP scale (P = .007) in the first hour of cHD and remained unaltered thereafter [+0.10 points/h (P = .20)]; thermal perception remained unaltered [0.04 points/h (P = .77)] in the other modalities. CONCLUSION Intradialytic symptomatology was, except for the symptom feeling cold, by and large similar in all modalities, but it varied markedly between patients. Hence, adverse intradialytic symptoms seem largely patient-specific. Patients experienced more cold sensations during cool HD, but not during haemodiafiltration.

MO657: Low Incidence of Intradialytic Hypotension During Online Post-Dilution High-Volume Haemodiafiltration: A Randomized Cross-Over Trial between Four Intermittent Dialysis Modalities

Abstract BACKGROUND AND AIMS Compared with standard haemodialysis (S-HD), online post-dilution haemodiafiltration (HDF) is associated with improved survival, especially when high convection volumes [high-volume (HV)-HDF] are achieved [1]. A superior intradialytic haemodynamic stability may play an important role in this respect. Therefore, we assessed whether the intradialytic haemodynamic profile differs between four dialysis modalities, including S-HD and HV-HDF. METHOD In the current randomized cross-over trial (NCT03249532, ClinicalTrials.gov), 40 prevalent dialysis patients were subjected to S-HD [dialysate temperature (Td) 36.5°C], HD with cool dialysate (C-HD; Td 35.5°C), low-volume (LV)-HDF [convection volume (CV) 15 L/1.73 m2/session) and HV-HDF (CV ≥23 L/1.73 m2/session) (both Td 36.5°C). Blood pressure (BP) was measured 4x/hour. The primary endpoint was the total number of intradialytic hypotensive (IDH) episodes. IDH was defined as a nadir in systolic BP (SBP) &amp;lt;90 mmHg for a pre-dialysis SBP &amp;lt;160 mmHg and &amp;lt;100 mmHg for a pre-dialysis SBP ≥160 mmHg, independent of symptoms and interventions. In addition, an explorative analysis was performed on the incidence of early-onset IDH, which has recently been related to mortality [2]. Secondary endpoints included the intradialytic courses of SBP, diastolic BP (DBP) and mean arterial pressure (MAP). RESULTS IDH occurred significantly less frequent during C-HD (0.21 episodes/session) and HV-HDF (0.27/session) compared with S-HD (0.68/session, both P &amp;lt; .0005) (Figure 1). Furthermore, early-onset of IDH was also observed more frequently during S-HD (0.32/session) than during C-HD (0.07/session, P&amp;lt;.0005) or HV-HDF (0.10/session, P = .001) (Figure 1). After correction for multiple testing, the intradialytic courses of SBP, DBP and MAP declined only significantly during S-HD (−6.8, −5.2, −5.2 mmHg/session; P = .004, &amp;lt;.0005, .002 resp.) whereas these remained stable in the other modalities (Table 1). CONCLUSION In conclusion, during both C-HD and HV-HDF, IDH occurred least frequent and the intradialytic haemodynamic stability was best preserved. In contrast, intradialytic haemodynamic stability is most dysregulated during S-HD. Therefore, it is conceivable that the survival benefit of HV-HDF over S-HD is (at least partly) due to a more stable intradialytic haemodynamic profile and consequently less repetitive tissue injury.