Dialysis Hypotension Research Articles

Tocilizumab improves cardiac disease in a hemodialysis patient with AA amyloidosis secondary to rheumatoid arthritis

A 58-year-old Japanese woman on hemodialysis (HD) was admitted for intractable rheumatoid arthritis. Even after HD was started due to end-stage renal failure in 2004, her arthropathy worsened. A soluble tumor necrosis factor receptor inhibitor (etanercept at 25 mg twice weekly), tacrolimus (2 mg daily), and prednisolone (10 mg daily) had been administered since 2005, but high disease activity had persisted. She was admitted to our hospital in July 2007. C-reactive protein (CRP) was 6.8 mg/dL, and the DAS-CRP score was calculated to be 8.3. The cardiothoracic ratio (CTR) was 62% on a chest radiograph, but dialysis hypotension was remarkable. Left ventricular mass (LVM) was calculated as 320 g using echocardiography. Endoscopic biopsy of the stomach and duodenum revealed heavy deposition of AA amyloid. Etanercept was discontinued and tocilizumab was started at a dose of 320 mg (8 mg/kg) monthly. Even after predonisolone and tacrolimus were tapered gradually and discontinued because of her good response, CRP and DAS-CRP became 0.0 mg/dL and 1.5, respectively. In September 2011, re-evaluation was performed. CTR was reduced to 51% and LVM was decreased to 180 g. Endoscopic biopsy of the stomach and duodenum revealed disappearance of AA amyloid. Although AA amyloidosis of the gastrointestinal tract has already been reported to be improved by tocilizumab, this is the first report on improvement of myocardial hypertrophy as well as dialysis hypotension.

Critical Evaluation of Blood Volume Measurements during Hemodialysis

Devices that continuously measure relative blood volume (RBV) changes during hemodialysis (HD) are increasingly used for the prevention of dialysis hypotension and fine-tuning of dry weight. However, RBV measurements are subject to various limitations. First, RBV devices provide information on relative blood volume changes but not on absolute blood volume. Since blood volume varies with the hydration status, identical reductions of RBV may result in very different absolute blood volumes at the end of HD. Second, RBV changes underestimate the change of total blood volume due to translocation of lower-hematocrit blood from the microcirculation to the central circulation. Third, changes in posture before and during HD, food intake, exercise, and administration of intravenous fluids may influence the validity of the RBV measurement. Fourth, results obtained by various RBV devices show large interdevice differences. Finally, although a fall in blood volume is an important factor in dialysis hypotension, frank dialysis hypotension only occurs when the cardiovascular compensatory mechanisms can no longer compensate for the reduction in blood volume. Therefore, the dialysis staff should not exclusively focus on RBV, but also search for opportunities in the dialysis prescription to facilitate cardiovascular compensatory mechanisms, e.g. by lowering dialysate temperature. In the opinion of the authors, routine RBV monitoring should be used with caution until the major conceptual and methodological problems that are inherent to the indirect RBV estimation are clarified.

Is the risk of dialysis hypotension predictable based on on-line analysis of oxygen saturation (SO 2 ) during hemodialysis? A multicenter study

Is the risk of dialysis hypotension predictable based on on-line analysis of oxygen saturation (SO 2 ) during hemodialysis? A multicenter study

Vasopressin secretion by hypertonic saline infusion during hemodialysis: effect of cardiopulmonary recirculation

Intradialytic hypotension is the most common and severe acute complication of hemodialysis therapy. In our previous study, infusion of 20 mL of 10% saline into the venous line of a dialyzer increased blood pressure during dialysis hypotension by stimulating arginine vasopressin (AVP) secretion, independent of its effect on plasma volume (PV). This study examines the mechanism by which a small amount of hypertonic solution stimulates AVP secretion. Hemodialysis patients were infused with 20 mL of 2.5 M saline (100 mOsm) over 5 (Protocol 1) or 2 min (Protocol 2) or with isotonic saline (Protocol 3) into the venous line. Arterial plasma osmolality (Posm) increased by 28.1 and 16.0 (P < 0.0001), while peripheral venous Posm increased by only 8.6 and 8.9 mOsm/kg H(2)O (P < 0.001) in Protocols 2 and 1, respectively. Plasma AVP (P(AVP)) increased significantly by 18.6 and 5.6 pg/mL, PV by 7.2 and 5.5% and mean arterial pressure (MAP) by 15.0 and 7.2 mmHg in Protocols 2 and 1, respectively. Thus, there were large differences in Posm between arterial and peripheral venous blood; osmolar gap, P(AVP) and MAP increased in proportion to the infusion rate. Isotonic saline (30.8 mOsm) infusion increased PV by 8.7% and MAP by 7.2 mmHg. Our results indicate that by a mechanism similar to cardiopulmonary recirculation, hypertonic saline infusion caused a striking increase in arterial Posm that enhanced AVP secretion and raised blood pressure. The effect of hypertonic saline on PV was less than one-third of isotonic saline under similar osmolar loads.

Rate Response Function of Pacemaker with Closed-Loop Stimulation (CLS) to Blood Pressure Variation during Dialysis in a Bradycardia Patient

Purpose: The patient was a 70-year old male under maintenance dialysis because of diabetic nephropathy. For his advanced atrioventricular block, we implanted a pacemaker (PM) with CLS function (Entovis DR/CLS, Nihon Kohden, BIOTRONIK) (DDD-CLS, basic rate 60 ppm) and then monitored heart rate response during dialysis. Results: Until 120 minutes after start of dialysis, systolic blood pressure (Ps) and heart rate (HR) shifted in the ranges of 158 to 167 mmHg and 60 to 63 bpm in the pacing behavior of As-Vp. About 130 to 140 minutes after start of dialysis, Ps suddenly dropped from 178 to 159 mmHg, then As-Vp changed to Ap-Vp with an increased atrial paing rate of up to 69 ppm earlier than an increase of patient’s sinus rate, so that Ps had a tendency of early recovery. Discussion: It may be possible that when Ps dropped suddenly, CLS function detected intracardiac impedance changes which reflected changes in myocardial contraction dynamics yielded by circulating blood volume reduction due to water removal during dialysis. Conclusion: When blood pressure drops during dialysis with little body motion, an increase of atrial pacing rate by PM with CLS function may help recover blood pressure early. We will accumulate data further in order to investigate effectiveness of cardiac pacing for dialysis hypotension.

Vascular access graft thrombosis by iatrogenic fistula

AbstractProsthetic arteriovenous graft thrombosis is multifactorial and includes stenosis of the graft‐venous and graft‐arterial anastomosis, excessive compression for hemostasis at the end of dialysis, complication of dialysis needle placement, hypotension, hypovolemia, and hypercoagulable states. We report a case of arteriovenous graft thrombosis resulting from a traumatic fistula between an arteriovenous graft and the adjacent basilic vein related to repeated cannulation. A 49‐year‐old female with end‐stage renal disease visited our department with a thrombosed left forearm arteriovenous graft. On physical examination, there was strong pulsation on the arterial limb of the graft, but no thrill and bruit on the venous limb. Fistulography was performed for endovascular treatment of the arteriovenous graft thrombosis. However, it showed a fistula arising from the dialysis graft and communicating with the adjacent basilic vein. The purpose of this discussion is to highlight a rare cause of vascular access graft thrombosis including etiology, pathophysiology, diagnosis, prevention, and treatment.

Protect your patient from dialysis hypotension

Rick Jepson is supervisor of inpatient dialysis at Utah Valley Regional Medical Center in Provo. Learn about the risk of this complication in patients undergoing hemodialysis and how you can help prevent it.

Left-Ventricular Diastolic Dysfunction as a Risk Factor for Dialytic Hypotension

Objectives: Intradialytic hypotension may adversely affect the outcome of chronic hemodialysis and thus reduce the patients’ life expectancy. The aim of this study was to assess the link between left-ventricular diastolic dysfunction and dialytic hypotension. Methods: We performed a prospective cross-sectional study of 72 hemodialysis patients with a low dialysis vintage, 36 of whom had dialysis hypotension, based on echocardiography and brain natriuretic peptide (BNP) assay. Results: There was no difference between normotensive patients and those with dialysis-associated chronic hypotension as regards BNP level, cardiac index, left-ventricular ejection fraction, or myocardial fractional shortening. Both hypotension-prone patients requiring dialysate sodium profiling and chronic refractory hypotensive patients requiring macromolecule infusion had cardiac diastolic dysfunction as shown by a similarly abnormal E/A ratio <1 in 89–91% of cases, associated with a significant decrease in color M-mode diastolic flow propagation velocity (V_p, p < 0.05 nonparametric ANOVA). The area under the ROC curve for V_p was 0.69. A V_p cutoff of 39.5 cm/s was optimal for predicting dialysis-associated hypotension. Conclusions: We conclude that diastolic dysfunction is associated with dialytic hypotension and that a low V_p – a preload-independent index – is predictive of dialysis-associated hypotension.

Anterior Ischaemic Optic Neuropathy (AION) Associated with Post Dialysis Hypotension

Three patients on haemodialysis presented with acute painless visual loss. From each, a comprehensive medical and ophthalmic history was taken and each underwent a complete ophthalmic examination. Visual evaluation was carried out by recording Snellen visual acuities, Ishihara colour test scores, the presence of a relative afferent pupillary defect (RAPD) and visual fields with either Goldmann or Humphrey perimetry. Review of renal case notes was performed and appropriate laboratory investigations including imaging were carried out to investigate the cause of disc swelling in all cases. All cases presented with acute painless visual loss, a RAPD, disc swelling, impaired colour vision and a visual field defect. All cases had a history of post-dialysis hypotension. In 2 cases, post-dialysis hypotension was documented just prior to the development of anterior ischaemic optic neuropathy (AION) suggesting a causal relationship. Falls in mean arterial pressure (MAP) of 31 and 22 mmHg were recorded. None of the cases had other well documented risk factors for AION such as diabetes or hypercholesterolaemia. One case had crowded discs. Two cases had bilateral involvement. Two cases were treated with corticosteroids and 1 with aspirin. Visual improvement was noted in 1 case coincident with corticosteroid treatment. Common risk factors in all 3 cases were anaemia and post-dialysis hypotension. In conclusion, patients undergoing haemodialysis may be at risk of AION particularly if they are anaemic and develop post-dialysis hypotension. They should be informed of a small and unpredictable risk of visual loss.

The Effect of On-line High-flux Hemofiltration Versus Low-flux Hemodialysis on Mortality in Chronic Kidney Failure: A Small Randomized Controlled Trial

Given the paucity of prospective randomized controlled trials assessing comparative performances of different dialysis techniques, we compared on-line high-flux hemofiltration (HF) with ultrapure low-flux hemodialysis (HD), assessing survival and morbidity in patients with end-stage renal disease (ESRD). An investigator-driven, prospective, multicenter, 3-year-follow-up, centrally randomized study with no blinding and based on the intention-to-treat principle. Prevalent patients with ESRD (age, 16 to 80 years; vintage > 6 months) receiving renal replacement therapy at 20 Italian dialysis centers. Patients were centrally randomly assigned to HD (n = 32) or HF (n = 32). All-cause mortality, hospitalization rate for any cause, prevalence of dialysis hypotension, standard biochemical indexes, and nutritional status. Analyses were performed using the multivariate analysis of variance and Cox proportional hazard method. There was significant improvement in survival with HF compared with HD (78%, HF versus 57%, HD) at 3 years of follow-up after allowing for the effects of age (P = 0.05). End-of-treatment Kt/V was significantly higher with HD (1.42 +/- 0.06 versus 1.07 +/- 0.06 with HF), whereas beta(2)-microglobulin levels remained constant in HD patients (33.90 +/- 2.94 mg/dL at baseline and 36.90 +/- 5.06 mg/dL at 3 years), but decreased significantly in HF patients (30.02 +/- 3.54 mg/dL at baseline versus 23.9 +/- 1.77 mg/dL; P < 0.05). The number of hospitalization events for each patient was not significantly different (2.36 +/- 0.41 versus 1.94 +/- 0.33 events), whereas length of stay proved to be significantly shorter in HF patients compared with HD patients (P < 0.001). End-of-treatment body mass index decreased in HD patients, but increased in HF patients. Throughout the study period, the difference in trends of intradialytic acute hypotension was statistically significant, with a clear decrease in HF (P = 0.03). This is a small preliminary intervention study with a high dropout rate and problematic generalizability. On-line HF may improve survival independent of Kt/V in patients with ESRD, with a significant decrease in plasma beta(2)-microglobulin levels and increased body mass index. A larger study is required to confirm these results.

The influence of blood volume‐controlled ultrafiltration on hemodynamic stability and quality of life

Dialysis hypotension occurs frequently and is associated with increased morbidity, mortality, and may influence quality of life. We investigated the influence of blood volume (BV)-controlled ultrafiltration on hemodynamic stability and quality of life in a prospective multiple crossover study. Nineteen patients were consecutively treated with standard hemodialysis (HD), BV-controlled ultrafiltration, and again with standard ultrafiltration during 3-week phases, during which different hemodynamic parameters, ultrafiltrate quantities, dry weight, and quality of life were measured. Blood volume-controlled ultrafiltration resulted in increased hemodynamic stability: systolic blood pressure was significantly higher after treatment with BV-controlled HD compared with both standard treatments (p=0.018 and 0.043, respectively). Also, systolic blood pressure reduction, as a measure of blood pressure stability, was significantly smaller during the BV-controlled phase (-3.9 mmHg) compared with both standard phases (-13.7 and -11.0 mmHg): p=0.003 and 0.035, respectively. No difference was found in the occurrence of large decreases of blood pressure (>30 mmHg), decreases below 90 mmHg systolic pressure, or subjective complaints during treatment or after treatment between both treatment modalities. During the course of the study, the dry weight decreased significantly from mean 73.3 to mean 70.9 kg, and the amount of ultrafiltrate was significantly larger using BV-controlled HD compared with standard treatment (mean 2407 vs. mean 2266 mL; p=0.035). Quality of life, measured by visual analog scales (VAS), showed discrete but no consistent differences between study phases. We conclude that BV-controlled HD increases hemodynamic stability and ultrafiltrate amount compared with a standard treatment. No consistent change in quality of life is found between both treatment modalities.

The Pulsed Doppler Predictors of Intra Dialysis Hypotension and Relationship between Doppler Indices and Net Fluid Loss after Dialysis in Patients with End Stage Renal Disease: Pulsed Doppler Study

Background: In patients with end stage renal disease (ESRD) on regular haemodialysis (HD), fluid status in the body has an important impact on the left ventricular (LV) filling and it can lead to intra-dialysis hypotension. The aim of the study is to study the pattern of diastolic pulsed Doppler filling in patients who had hypotension during HD and to correlate that with the net fluid loss at end of dialysis session. Material: Fifty two patients with (ESRD) on regular HD, 34 male, with mean age of 45.5 ± 13 year were studied. Each patient had pulsed Doppler study before and immediately after HD. Each patient was observed for the development of acute clinical events and hypotension defi ned as systolic blood pressure of less than 90 mmHg. Patients were divided into two groups according to the amount of net ultra fi ltrate loss after HD, group I (n = 25) with fluid loss of 2 litres. Results: The mean age was 45 ± 12 year for group I and 46 ± 11 year for group II. In the study group, 11 out of 52 (21%) patients developed systolic hypotension less than 90 mmHg during HD compared to those without, no patient necessitate HD discontinuation. The mean pre dialysis pulsed Doppler Early filling to late filling wave (E/A ratio) of those who developed hypotension was (0.7 ± 0.2 vs. 1.1 ± 0.2.1, p < 0.001) and the mean of Deceleration time of E wave (DT) (246 ± 40 vs. 224 ± 34 m.sec, p < 0.05) respectively. The mean difference between pre and post HD pulsed Doppler indices in group II compared with group I were as follow: the mean reduction of E wave velocity (32 ± 17 vs. 12 ± 15 m.sec, p < 0.01), the mean reduction of A wave velocity (13 ± 17 vs. 11 ± 16 m.sec, p = NS), E/A ratio reduced to 0.14 ± 0.03 vs. 0.01 ± 0.04, p < 0.05), the mean DT of E wave increase from (43 ± 51 vs. 16 ± 64 m.sec, p < 0.05). Conclusion: In patient ESRD on regular hemodialysis, the prolonged DT >246 m.sec of E wave and E/A ratio less than 0.7 both may be used as a predictors of asymptomatic hypotension during HD. The net fluid loss during HD is directly proportional to the reduction of left ventricle Doppler diastolic indices.

Hemodiafiltration History, Technology, and Clinical Results

Hemodiafiltration (HDF) is an extracorporeal renal-replacement technique using a highly permeable membrane, in which diffusion and convection are conveniently combined to enhance solute removal in a wide spectrum of molecular weights. In this modality, ultrafiltration exceeds the desired fluid loss in the patient, and replacement fluid must be administered to achieve the target fluid balance. Over the years, various HDF variants have emerged, including acetate-free biofiltration, high-volume HDF, internal HDF, paired-filtration dialysis, middilution HDF, double high-flux HDF, push-pull HDF, and online HDF. Recent technology has allowed online production of large volumes of microbiologically ultrapure fluid for reinfusion, greatly simplifying the practice of HDF. Several advantages of HDF over purely diffusive hemodialysis techniques have been described in the literature, including a greater clearance of urea, phosphate, beta(2)-microglobulin and other larger solutes, reduction in dialysis hypotension, and improved anemia management. Although randomized controlled trials have failed to show a survival benefit of HDF, recent data from large observational studies suggest a positive effect of HDF on survival. This article provides a brief review of the history of HDF, the various HDF techniques, and summary of their clinical effects.

Prevention of dialysis hypotension episodes using fuzzy logic control system

Prevention of dialysis hypotension episodes using fuzzy logic control system

RELATIVE BLOOD VOLUME BASED BIOFEEDBACK DURING HAEMODIALYSIS

Intra-dialytic hypotension is the most frequently occurring complication during haemodialysis and can lead to serious complications. Devices that continuously and non-invasively monitor relative blood volume (RBV) changes during HD are being advocated as a tool to maintain an adequate volume of the intravascular compartment in order to avoid dialysis hypotension. Nowadays, most manufacturers have incorporated a RBV monitor in their dialysis apparatus and two manufacturers have designed biofeedback devices that control intra-dialytic RBV changes. The goal of RBV based biofeedback systems is to prevent a severe or abrupt decrease in blood volume in order to prevent the development of dialysis hypotension. Biofeedback technologies can diminish the severity and/or frequency of dialysis hypotension. At present, however, a completely symptom-free HD is not a reality. The major reasons for this are patient characteristics such as cardiovascular co-morbidity and high UF rates and a lack of understanding of the relation between RBV changes and blood pressure/cardiovascular stability.

Prevention of dialysis hypotension episodes using fuzzy logic control system

Automatic systems for stabilizing blood pressure (BP) during dialysis are few and only control those variables indirectly related to BP. Due to complex BP regulation under dynamic dialysis conditions, BP itself appears to be the most consistent input parameter for a device addressed to preventing dialysis hypotension (DH). An automatic system (ABPS, automatic blood pressure stabilization) for BP control by fluid removal feedback regulation is implemented on a dialysis machine (Dialog Advanced, Braun). A fuzzy logic (FL) control runs in the system, using instantaneous BP as the input variable governing the ultrafiltration rate (UFR) according to the BP trend. The system is user-friendly and just requires the input of two data: critical BP (individually defined as the possible level of DH risk) and the highest UFR applicable (percentage of the mean UFR). We evaluated this system's capacity to prevent DH in 55 RDT hypotension-prone patients. Sessions with (treatment A) and without (treatment B) ABPS were alternated one-by-one for 30 dialysis sessions per patient (674 with ABPS vs 698 without). Despite comparable treatment times and UF volumes, severe DH appeared in 8.3% of sessions in treatment A vs 13.8% in treatment B (-39%, P=0.01). Mild DH fell non-significantly (-12.3%). There was a similar percentage of sessions in which the planned body weight loss was not achieved and dialysis time was prolonged. In conclusion, FL may be suited to interpreting and controlling the trend of a determined multi-variable parameter like BP. The medical knowledge of the patient and the consequent updating of input parameters depending on the patient's clinical conditions seem to be the main factors for obtaining optimal results.

Vasopressin: A look at dialysis hypertension and autonomic dysfunction

Dialysis hypertension is a complex disorder in which ambient vascular resistance is too high for the blood volume. van der Zee et al. remind us that this is contingent upon the endothelium itself, and that endothelial dysfunction is integral to uremia. Thus, while vasopressin may not abolish dialysis hypotension, its effects highlight the influence of uremia on the autocrine and neuroendocrine control of cardiovascular physiology.

Evidence based nursing about the influence factors of dialysis hypotension

透析时低血压是血液透析的严重并发症.近年来,尽管血液净化技术有很大改进,但透析低血压的发生率仍为25%～50%[1]几乎没有下降.根据患者的个体差异及其发生透析低血压的原因,利用循证护理理论与方法,制订相适应的透析模式,可使透析低血压发生率有所下降,现报道如下。

Pathogenesis and treatment of dialysis hypotension

Dialysis-induced hypotension (DIH) is a very serious clinical problem. It is one of the most frequent complication in renal replacement therapy which diminish patient's quality of life, and increases mortality in the dialyzed population. The main mechanism of DIH is rapid reduction of blood volume owing to ultrafiltration and decrease in extracellular osmolarity during the dialysis session. Coexisting illnesses, especially cardiovascular diseases, particularly common in older and diabetic patients have an essential meaning in the episodes of dialytic hypotension. Efficient treatment of DIH is difficult owing to no generally accepted guidelines – is still a great challenge to the nephrologist. Multilevel strategy of DIH management includes emergency replacement of intravascular volume in acute episodes of hypotonia, accurate assessment of ‘dry weight', education of the patient, adequate hypertension treatment, and assessment methods strictly related to hemodialysis procedure such as low dialysate temperature, longer dialysis sessions or daily dialysis, sodium profiling or application of the modern dialysis technique as biofeedback equipment. There is also a possibility for pharmacological treatment with the use of such agents – as the well described midodrine, or other drugs such as caffeine, effedrin, and vasopressin analogs. The new class of drugs which can be a novel therapeutic option for DIH treatment are adenosine receptor antagonists and selective inhibitors of the inducible form of nitric oxide synthase. Besides the discussed strategies, efficient treatment of congestive heart failure, a common reason of hypotension in uremic patients, should not be overlooked.

Treatment of post-dialytic orthostatic hypotension with an inflatable abdominal band in hemodialysis patients

The purpose of this study was to ascertain whether abdominal compression with an inflatable abdominal band, a device we developed, improved post-dialytic orthostatic hypotension (OH) in hemodialysis (HD) patients. Twenty-five chronic HD patients with intractable post-dialytic OH were recruited. Post-HD changes in systolic blood pressure (DeltaSBP) in the supine and standing positions were compared in the patients, measured with or without the use of the band. The study showed DeltaSBP after HD without the band was significantly greater than that measured before HD (-36.1+/-18.2 vs -13.1+/-16.8 mm Hg; P<0.0001). DeltaSBP after HD with the band was reduced significantly in comparison to DeltaSBP after HD without the band (-19.4+/-21.2 vs -36.1+/-18.2 mm Hg; P<0.002). Use of the band did not cause an elevation in SBP in the supine position (149.0+/-29.6 vs 155.4+/-25.7 mm Hg); however, it did increase SBP upon standing (129.6+/-27.3 vs 117.2+/-22.6 mm Hg; P<0.05). Eight patients in whom an increase in SBP of 25 mm Hg or more was achieved with the band were classified as responders. Ejection fraction was significantly higher (76.4+/-11.1 vs 61.9+/-13.6%; P<0.02) and atrial natriuretic peptide concentration significantly lower (27.9+/-22.0 vs 68.9+/-47.5 pg/ml; P<0.02) in responders than in non-responders. We conclude that the abdominal band was effective for overcoming post-dialytic OH, without elevating supine SBP in some patients.