Frequency Of Intradialytic Hypotension Research Articles

Effect of Pre- and Post-Dialysis Exercise on Functional Capacity Using Portable Ergometer in Chronic Kidney Disease Patients.

To assess whether performing exercises during hemodialysis reduces the risk of developing intradialytic hypotension and enhances exercise capacity in patients with chronic kidney disease. This study included patients aged ≥18 years undergoing hemodialysis. Participants performed exercises using a portable lower extremity ergometer during hemodialysis sessions for 3 weeks. Data regarding walking distance, knee strength, quality of life, fat-free mass, arterial pressure, blood pressure, heart rate, frequency of intradialytic hypotension, fatigue, and duration of hemodialysis were collected and analyzed. Significant improvements in walking distance and knee strength were observed following the implementation of exercise training during hemodialysis. Although there was no significant reduction in the frequency of intradialytic hypotension, a decreasing trend was noted. Other parameters such as quality of life and fatigue did not show significant changes. Using a portable ergometer during hemodialysis improved exercise capacity and knee strength in patients with chronic kidney disease. There was a trend toward reduced intradialytic hypotension, suggesting potential cardiovascular benefits. Further research with larger sample sizes is needed to confirm these findings.

Association of Calcium Channel Blocker Use With Intradialytic Hypotension in Maintenance Hemodialysis

IntroductionCalcium channel blockers (CCBs) are common anti-hypertensive agents among patients receiving hemodialysis (HD). Despite this, the association of CCBs with intra-dialytic hypotension (IDH), an important adverse outcome that is associated with cardiovascular morbidity and mortality, remains largely unexplored. MethodsUsing kinetic modeling sessions data from the Hemodialysis Study, random-effects regression models were fit to assess the association of CCB use versus not with IDH (defined as systolic blood pressure (SBP)<90 mmHg if pre-HD SBP<160 mmHg or <100 mmHg if pre-HD SBP≥160 mmHg). Models were adjusted for age, sex, race, randomized Kt/V and flux assignments, heart failure, ischemic heart disease, peripheral vascular disease, diabetes mellitus, blood urea nitrogen, ultrafiltration rate, access type, pre-HD SBP, and other anti-hypertensives. ResultsData was available for 1,838 patients and 64,538 sessions. At baseline, 49% of patients were prescribed CCBs. The overall frequency of IDH was 14% with a mean decline from pre-to nadir-SBP of 33±15 mmHg. CCB use was associated with lower adjusted risk of IDH, compared with no use (incidence rate ratio [IRR] 0.84; 95%CI 0.78, 0.89). The association was most pronounced for those in the pre-HD SBP lowest quartile (IRR 0.77;95%CI 0.70, 0.85), compared with the highest quartile (IRR 0.86; 95%CI 0.77, 0.97; P-interaction<0.001). ConclusionAmong patients receiving HD, CCB use was associated with a lower risk of developing IDH, independent of pre-HD SBP and other anti-hypertensive use. Mechanistic studies are needed to better understand the effects of CCB and other anti-hypertensives on peri-dialytic blood pressure parameters among patients receiving HD.

Transcatheter aortic valve replacement in patients with severe aortic stenosis reduced the frequency of intradialytic hypotension.

Intradialytic hypotension (IDH) is a common complication during hemodialysis that increases cardiovascular morbidity and mortality. Aortic stenosis (AS) is a cause of IDH. Transcatheter aortic valve replacement (TAVR) has become an established treatment for patients with severe AS. However, whether TAVR reduce the frequency of IDH has not been investigated. This study aims to verify the efficacy of TAVR for reduction of the frequency of IDH. Consecutive hemodialysis patients who underwent TAVR at Sendai Kosei Hospital from February 2021 to November 2021 with available records 1month before and 3months after TAVR were included in the study. IDH was defined as a decrease in systolic blood pressure by 20mmHg or a decrease in the mean blood pressure by 10mmHg associated with hypotensive symptoms or requiring intervention. Patients with ≥ 3 episodes of IDH in ten hemodialysis sessions comprised the IDH group. Overall, 18/41 (43.9%) patients were classified into the IDH group. In ten hemodialysis sessions, IDH events were observed 2.1, 4.3, and 0.4 times in the overall cohort, IDH group, and non-IDH group, respectively. After TAVR, the incidence of IDH decreased from 43.2 to 10.3% (p < 0.0001) and IDH improved significantly in 15 patients in the IDH group. The result suggested that severe AS was the major cause of IDH in this cohort, and TAVR may be an effective treatment option for reduction of the frequency of IDH in patients with severe AS.

Frequency of intradialytic hypotension in patients with chronic kidney disease.

Objective: To find the frequency of intradialytic hypotension in chronic kidney disease. Study Design: Cross Sectional Descriptive study. Setting: Hemodialysis Unit of Ayub Teaching Hospital Abbottabad. Period: March 2019 to June 2019. Material &amp; Methods: A total of 95 patients, fulfilling the inclusion criteria were enrolled in the study. After taking consent, relevant history was taken along with physical examination performed. The medical record including various investigations was reviewed. Blood pressure was recorded at regular intervals during the ongoing hemodialysis session of selected patients by the staff of hemodialysis unit, using bedside mercury manometer. Results: Out of 95, 47 patients (49%) developed intradialytic hypotension in the middle of their hemodialysis sessions. There was no significant difference in the frequencies of intradialytic hypotension with respect to gender and age. Conclusion: Hemodialysis is a life saving treatment modality. Despite advances in technology it carries a number of complications. Intradialytic hypotension is one of its frequent complications with a fact that it has no consensus definition. Its frequency in chronic kidney disease patients visiting hemodialysis unit of Ayub Teaching Hospital Abbottabad is high. The high frequency necessitates various interventions for its prevention and further research is required in this regard.

PS-C18-9: THE ASSOCIATION BETWEEN FRAILTY OR SARCOPENIA AND INTRADIALYTIC HYPOTENSION

Objective: Recently, osteoporosis, sarcopenia, and frailty have become prognostic issues due to the increasing number and aging population of dialysis patients. Dialysis patients have high bone and muscle fragility due to their unique pathology, and we previously investigated the association between osteoporosis and muscle mass or strength in the cross-sectional study. We found that shorter calf circumference and weaker grip strength were associated with lower bone mineral density and the risk for osteoporosis among hemodialysis patients, independently of the management of chronic kidney disease-mineral and bone disorder, nutritional status, and dialysis adequacy. On the other hand, intradialytic hypotension is also one of the most common intradialytic complications, which can affect dialysis adequacy and prognosis. Although sarcopenia and frailty have been reported to cause orthostatic hypotension, the association between sarcopenia or frailty and intradialytic hypotension is not clear. Therefore, in this study, we examined the association between sarcopenia or frailty and intradialytic hypotension using our previous osteoporosis study. Design and method: This was a single-center cross-sectional study. We screened patients aged 20 years or older who underwent hemodialysis three times a week and selected 200 patients with a history of hemodialysis for at least 6 months for the study. Calf circumference, grip strength, and normal walking speed were measured to assess sarcopenia, and frailty was diagnosed based on the Japanese version of the Cardiovascular Health Study criteria. The behavioral characteristics and clinical history were obtained using a questionnaire and medical records. We analyzed the association between the frequency of intradialytic hypotension and frailty, or physical functions related to sarcopenia. Results: The final analysis included 121 subjects, mean age 66.1 ± 12.6 years, 28 women (23.1%). Mean calf circumference was 35.6 cm ± 3.8 cm, grip strength was 27.8 kg ± 9.6 kg, 26 (21.5%) were frail, 64 (52.9%) were prefrail, and 31 (25.6%) were robust. We are currently collecting and analyzing the data and will present our findings at the conference. Conclusions: We plan to present the relationship between intradialytic hypotension and frailty or physical function at the conference.

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

BackgroundCognitive 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.MethodsThis 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.DiscussionThe 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 registrationClinicalTrials.gov NCT03645733. Registered retrospectively on 24 August 2018.

P1491INTRADIALYTIC HYPOTENSION AND PROGOSIS IN HEMODIALYSIS PATIENTS

Abstract Background and Aims The aim of this study was to investigate the prognostic impact of intradialytic hypotension (IDH). Method This study comprised 237 hemodialysis patients (158 males, 64±13 years old, dialysis vintage:110±88 months) in a community-based dialysis center. IDH was recorded in 12 consecutive hemodialysis sessions from February to April in 2014. The patients were divided into 2 groups: Group A, patients with IDH, and Group B, those without IDH, and all-cause mortality rates for 4 years were examined. IDH was defined as a rapid symptomatic fall of systolic blood pressure by at least 30 mmHg or that required medical intervention. Logistic regression was used to investigate the association between IDH and mortality. Results IDH was observed in 123 patients (52 %). The frequency of IDH was 3.8±3.1 times during 12 hemodialysis sessions in Group A. Mortality rates from all causes of death were significantly higher in Group A than in Group B (40 % and 17 % at 4 years, respectively, p &amp;lt; 0.05). Univariate analysis showed that IDH, age, female, dry weight, ultrafiltration rate (UFR), serum albumin level, and serum hemoglobin level were significantly associated with all-cause mortality. In multivariate analysis, IDH, age, UFR, and serum hemoglobin level were independent risk factors for all-cause mortality (Table). Conclusion In our population, IDH was associated with a poor prognosis at 4 years.

P1081DIALYSATE SODIUM ALLIGNMENT AND SODIUM SET-POINT STABILITY IN HEMODIALYSIS PATIENTS: TWO-YEAR OBSERVATION

Abstract Background and Aims The low dialysate sodium (NaD) reduces intradialytic weight gain (IDWG) and blood pressure (BP), which are associated with improved outcomes. However, the intervention probably also increases intradialytic hypotension and reduces serum sodium (NaS), that are associated with increased mortality risk, so NaD should be individualized and brought closer to NaS. Predialysis natraemia in hemodialysis (HD) patients is considered constant (set-point) but some observations contradict this statement. The significance of clinical parameters, dialysis parameters and body water distribution is not clear. Method We undertake the retrospective observation among 45 HD patients for 24 months before large-scale prospective intervention investigation for individualization of NaD. We used two-year routinely monthly fixed data: NaS, NaD, IDWG, frequency of intradialysis hyper- and hypotension and seizures, peri- and intradialysis BP, home BP estimates, clinically and by bioimpedance estimated dry weight, ultrafiltration rate, frequency and duration of HD sessions. Results We included 27 males and 18 females of 60 (34-83) years old, with median HD vintage of 63 (29÷93) months. 1048 NaS measurements revealed mean natraemia of 137.1±2.8 (Q5-Q95 132-141) mmol/l (corrected for glucose). No differences in mean NaS according to gender, age, HD vintage, cardiac or liver dysfunction and residual renal function were found. Intraindividual NaS mean varied from 132 to 141 mmol/l and median of coefficient of variation (CV) was 1.4% (1.2÷1.6) (range 0.9-2.0%) which could be attributed mainly to measurement accuracy. The intraindividual NaS Q10-Q90 did not exceed 6 mmol/l with its median 3.0 (2.7÷3.7). Among whole group we revealed slow decreasing NaD trend (-0.12 mmol/l per year, R?0.45) which was accompanied by more prominent trend in systolic BP (-3.3 mmHg/year, R?0.64) and diastolic BP (-1.6 mmHg/year, R?0.49). In parallel, the frequency of intradialytic hypotension increased by 1.6 episodes/100HD per year (mean 2.3±0.6 after excluding the trend). 33 patients (73%) showed no significant individual trend in NaS (&amp;lt;1 mmol/l per year) for 24 months, 8 (18%) demonstrated decreasing trend (mean -1.5 mmol/l per year) while only 4 (9%) - increasing trend (mean +1.6 mmol/l per year). We observed no trend in prescribed bicarbonate level in dialysate. There were no significant associations between intraindividual deviations from individual mean weight before HD and from mean individual NaS. In whole group, intraindividual variations in NaS had no link with mean NaS. We observed the significant variations in NaS only in patients with large CV of predialysis weight (Q90-Q10&amp;gt;5 kg over 2 years). Overall mean of sodium serum to dialysate gradient (NaG) was slightly positive (+0.15±3.0 mmol/l) while 58% of patients had negative or neutral NaG. The latter had lesser IDWG but no difference in intradialytic hypotension frequency. We evaluated the number of random consecutive monthly predialysis NaS need to get acceptable estimation of real mean two-year predialysis NaS: five values gave 94% hit in range -1÷ +1 mmol/l. Conclusion Serum sodium is stable over time in HD patients with the only exception of patients with large intraindividual predialysis weight variation. Pre-HD serum sodium may be used as a parameter for individualizing dialysate sodium prescription.

Intradialytic hypotension prevalence, influencing factors, and nursing interventions: prospective results of 744 hemodialysis sessions.

The aim of this study was to evaluate intradialytic hypotension (IDH) prevalence, influencing factors, and nursing interventions in hemodialysis (HD) patients. 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. 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). Nursing staff awareness regarding the frequency of IDH in hemodialysis patients and the related symptoms needs to be increased.

Effect of Hydrocortisone on Intradialytic Hypotension: A Preliminary Investigational Study.

Introduction Approximately 15 to 33% of all dialysis treatments are complicated by intradialytic hypotension (IDH). In this study, we tested the hypothesis that the intravenous administration of hydrocortisone prior to HD treatment could prevent IDH or at least decrease the drop in the blood pressure resulting from IDH. Methods This study was approved by our local ethics committee/IRB (2017/87) and by the Jordan Food and Drug Administration (7/clinical/18). Additionally, it is registered on ClinicalTrials.gov (NCT03465007). In this preliminary investigational study, we screened all chronic hemodialysis patients at our clinic who were 18 years of age or older (n = 82) for IDH. There were 14 patients included in the interventional part of this study; patients were given IV hydrocortisone for 3 consecutive HD sessions, followed or preceded by 3 intervention-free sessions where they were given 5 ml of saline as a placebo. Results The initial total sample size was 82 patients. The frequency of IDH at our clinic was 24.4%. Fourteen out of the 20 patients who were diagnosed with IDH agreed to enroll in the interventional part of our study. The mean age of the patients in the interventional part of our study was 53.5 years (±10.3). These patients included 5 (35.7%) men and 9 (64.3%) women. Upon comparing the number of hypotensive attacks with and without the hydrocortisone administration, we found a significant difference (p = 0.003) between the hydrocortisone and placebo treatments in which 12 (85.7%) patients had fewer IDH episodes with the hydrocortisone treatment than with placebo. Conclusion This preliminary investigational study found that the administration of a stress dose of hydrocortisone prior to hemodialysis could be an effective measure for preventing or minimizing the risk of IDH episodes. Additional prospective studies on this subject are needed. Ruling out adrenal insufficiency in patients diagnosed with IDH is also crucial.

SAT-240 INTER-DIALYTIC WEIGHT GAIN IN HEMODIALYSIS PATIENTS - EPIDEMIOLOGY AND EVALUATION OF THE CLINICAL OUTCOMES

Inter-dialytic weight gain (IDWG) has been linked to various complications in hemodialysis (HD) patients, especially cardiovascular (CV) complications. High ultrafiltration (UF) rate in relation to dialysis time has also a similar impact in various studies. Furthermore, high IDWG has been associated with all cause and CV mortality. The IDWG is also influenced by the nutritional status of HD patients. We investigated the trends of IDWG in patients on regular HD aiming to examine: (1) trends of IDWG among patients in relation to different variables and comorbidities e.g. age, hypertension, diabetes, CV disease...etc.; (2) associations of high IDWG with frequency of hospitalization due to systemic volume overload and the need for extra dialysis sessions, and (3) the impact of high IDWG on the frequency of intra-dialytic hypotension (IDH). One hundred and twenty maintenance HD patients were enrolled in this study. All patients had been receiving HD for at least 3 months, on a 4 hour, thrice weekly basis. The data collected included; age, gender, duration on HD (in months), pre- and post-HD body weights (on 3 successive sessions), pre- and post-HD blood pressure (BP) measurements (on 3 successive sessions), the type of vascular access and the average blood flow rate, dialysis efficiency (based on average Kt/V), and the presence or absence of residual kidney function. The presence of various comorbidities has been recorded including; diabetes, hypertension, coronary artery and peripheral vascular diseases, heart failure, cerebrovascular disease, and other disorders. The estimated IDWG was calculated based on the average between pre- and post- dialysis weights that were recorded on 3 consecutive dialysis sessions. The estimated IDWG was expressed in kilograms and as a percentage of the patients’ dry weight. We considered an estimated average IDWG of 4% as a cutoff value between low and high IDWG. We defined IDH as the drop of systolic blood pressure of 20 mmHg or more during HD compared to the pre-dialysis blood pressure and/or a systolic blood pressure that is less than 90 mmHg. We have recorded that 50.0% of those younger than 55 years had IDWG ≥ 4%. On the other hand, only 31.7% of those aged 55 years or more had IDWG ≥ 4% (p=0.041). There was no significant gender difference regarding IDWG. Among those who had IDWG ≥ 4%, 81% of these patients had at least one hospital admission due to volume overload or the need for extra HD session(s). On the other hand, only 19% of those having IDWG < 4% had been admitted or got extra HD sessions (p<0.001). Of those who were admitted (over 12 months) due to volume overload; 74.1 % had IDWG ≥ 4%, while 25.9% had IDWG < 4% (p< 0.001). Regarding IDH, 87% of patients having IDWG ≥ 4% had at least one episode of IDH/week. On the other hand, only 22.5% of those with IDWG < 4% had one episode of IDH/week (p<0.001). When analyzing those who had at least one IDH episode/week; 72.9% of them had IDWG ≥ 4%, while only 27.1% had IDWG < 4% (p<0.001).View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) In HD patients, the frequency of hospital admission due to volume overload and the need for extra HD sessions is strongly related to the amount of IDWG (> 4% in our patients). The same stands for the frequency of IDH. Thus a control of IDWG in HD patient is of great importance, keeping in mind the importance the nutritional status of HD patients that may also impact IDWG.

Intradialytic hypotension is an important risk factor for critical limb ischemia in patients on hemodialysis

BackgroundCritical limb ischemia (CLI) and intradialytic hypotension (IDH) are common complications in patients on hemodialysis (HD). However, limited data are available on whether IDH is related to CLI in these patients. The aim of this retrospective study was to evaluate whether IDH is a risk factor for CLI in HD patients.MethodsWe examined the frequency of IDH in 147 patients who received HD between January 1 and June 30, 2012. Blood pressure was measured during HD every 30 min and IDH was defined as a ≥ 20 mmHg fall in systolic blood pressure compared to 30 min before and a nadir intradialytic systolic blood pressure < 90 mmHg. The primary study outcome was newly developed CLI requiring revascularization treatment or CLI-related death. We assessed the association of IDH with outcome using a multivariable subdistribution hazard model with adjustment for male, age, smoking and history of cardiovascular disease.ResultsThe median follow-up period was 24.5 months. Fifty patients (34%) had episodes of IDH in the study entry period. During follow-up, 14 patients received endovascular treatment and CLI-related death occurred in 1 patient. Factors associated with incident CLI in univariate analysis were age, smoking, diabetes mellitus, peripheral arterial disease, history of cardiovascular disease, and IDH. IDH was significantly associated with the outcome with the subdistribution hazard ratio of 3.13 [95% confidence interval, 1.05–9.37].ConclusionsIDH was an independent risk factor for incident CLI in patients on HD.

Clinical evaluation of performance, biocompatibility, and safety of vitamin E-bonded polysulfone membrane hemodialyzer compared to non-vitamin E-bonded hemodialyzer

The vitamin E-bonded polysulfone membrane hemodialyzer (ViE™-21) was evaluated in a clinical study for regulatory submission. Seventeen patients on hemodialysis were treated with conventional high-flux hemodialyzers for 2 weeks (Pre-ViE phase) and switched to the ViE-21 for 36 sessions (ViE phase) followed by an additional 2 weeks on conventional hemodialyzers (Post-ViE phase). Reduction ratios of urea, creatinine, beta-2-microglobulin, albumin, and ultrafiltration coefficients (KUF) were measured once during the Pre-ViE phase and twice during the ViE phase. Moreover, biocompatibility markers [leucocyte count, platelet count, and activated complement factor (C3a) levels] were evaluated pre-dialysis, 15 min after initiation, and post-dialysis. During the study, type and number of adverse events (AEs), and device malfunctions were recorded. ViE-21 reduction ratios and KUF were not noticeably different than those of conventional hemodialyzers. Fluctuations of leucocyte counts and C3a concentrations were similar using ViE-21 and conventional hemodialyzers; however, the platelet count fluctuation was lower in ViE-21 sessions. The frequency of episodes of hypotension occurring during the ViE phase was lower than that occurring during the Pre- and Post-ViE phases. In conclusion, this study provided performance and safety data of the ViE-21 for regulatory application. The data suggest that vitamin E-bonded hemodialyzers are beneficial in lowering platelet activation and frequency of intradialytic hypotension. Larger randomized controlled trials are needed to confirm these findings.

Predicting intradialytic hypotension using heart rate variability

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.

A Pilot Study Evaluating the Effect of Cooler Dialysate Temperature on Hemodynamic Stability During Prolonged Intermittent Renal Replacement Therapy in Acute Kidney Injury.

Acute kidney injury requiring renal replacement therapy is associated with high morbidity and mortality. Complications of renal replacement therapy include hemodynamic instability with ensuing shortened treatments, inadequate ultrafiltration, and delay in renal recovery. Studies have shown that lowering dialysate temperature in patients with end-stage renal disease is associated with a decrease in the frequency of intradialytic hypotension. However, data regarding mitigation of hypotension by lowering dialysate temperature in patients with acute kidney injury are scarce. We conducted a prospective, randomized, cross-over pilot study to evaluate the effect of lower dialysate temperature on hemodynamic status of critically ill patients with acute kidney injury during prolonged intermittent renal replacement therapy. Single-center prospective, randomized, cross-over study. ICUs and a step down unit in a tertiary referral center. Acute kidney injury patients undergoing prolonged intermittent renal replacement therapy. Participants were randomized to start prolonged intermittent renal replacement therapy with dialysate temperature of 35°C or dialysate temperature of 37°C. The primary endpoint was the number of hypotensive events, as defined by any of the following: decrease in systolic blood pressure greater than or equal to 20 mm Hg, decrease in mean arterial pressure greater than or equal to 10 mm Hg, decrease in ultrafiltration, or increase in vasopressor requirements. The number of events was analyzed by Poisson regression and other outcomes with repeated-measures analysis of variance. Twenty-one patients underwent a total of 78 prolonged intermittent renal replacement therapy sessions, 39 in each arm. The number of hypotensive events was twice as high during treatments with dialysate temperature of 37°C, compared with treatments with the cooler dialysate (1.49 ± 1.12 vs 0.72 ± 0.69; incidence rate ratio, 2.06; p ≤ 0.0001). Treatment sessions with cooler dialysate were more likely to reach prescribed ultrafiltration targets. Patients with acute kidney injury undergoing prolonged intermittent renal replacement therapy with cooler dialysate experienced significantly less hypotension during treatment. Prevention of hemodynamic instability during renal replacement therapy helped to achieve ultrafiltration goals and may help to prevent volume overload in critically ill patients.

Blood Pressure Changes among Patients Undergoing Hemodialysis in Yenagoa, Nigeria.

Introduction:Hemodialysis (HD) is a common modality of renal replacement therapy in Nigeria. Despite its usefulness, it may have complications such as intra-dialytic hypotension (IDH) and intra-dialytic hypertension (IDHTN), both of which may impact negatively on the patient. The aim of the study was to examine blood pressure (BP) changes during HD, to determine the frequency of IDH and IDHTN in patients undergoing HD, and to possibly identify associated factors.Materials and Methods:The study design was a retrospective review of records of patients who had HD in the Rainbow Dialysis Center, a foremost private dialysis center in Bayelsa State. The records of all adults who had HD in the center from June 2014 to June 2018 were reviewed. Data retrieved include sociodemographics, type and cause of renal disease, and clinical and laboratory parameters such as BPs, packed cell volume, urea, and creatinine.Statistical Analysis Used:Data were analyzed with SPSS version 20.0. Data were presented in tabular forms. Variables were expressed as mean with standard deviation, frequencies, and percentages. The means were compared using Student's t-test or analysis of variance where appropriate. Chi-square test was used to compare proportions. Statistical significance was set at P < 0.05.Results:One hundred and thirty-six cases were recruited for the study. IDH and IDHTN were found in 16.9% and 16.2% of the patients, respectively. There was no significant difference between the mean predialysis and postdialysis systolic, diastolic, mean arterial BP, or pulse pressure (P > 0.05). Older age was positively and significantly associated with IDHTN (P = 0.047).Conclusions:IDH and IDHTN were prevalent among the patients studied, with the latter being slightly more likely to occur with advancing age. There is a need for adequate BP monitoring and management during HD.

Intradialytic hypotension in acute kidney injury requiring renal replacement therapy.

The treatment of severe acute kidney injury (AKI) with dialytic support for renal replacement therapy can be life sustaining and permit recovery from critical illness. Like any interventional therapy, however, renal replacement therapy with intermittent hemodialysis or continuous therapy can cause complications. Intradialytic hypotension is a common complication and can cause further ischemic injury to the recovering kidneys, thereby reducing the probability of renal recovery. The optimal dialytic technique-continuous or intermittent-has not been conclusively demonstrated in randomized controlled trials. In general, treatment or prophylactic strategies for intradialytic hypotension in AKI have not been comprehensively tested. Given the frequency of intradialytic hypotension in dialytic treatment of AKI and its adverse clinical consequences, future research should rigorously compare dialytic techniques and other prevention strategies in adequately powered, randomized controlled trials.

PS 08-41] EFFECT OF BLOOD PRESSURE AND DIALYSIS PARAMETERS BY DIALYSATE SODIUM CONCENTRATION ON SODIUM GRADIENT IN HEMODIALYSIS PATIENTS

Objective: In chronic hemodialysis (HD) patients, sodium (Na+) balance largely depends on interdialytic dietary salt intake and intradialytic Na+ removal. To preserve a neutral Na+ balance, interdialytic Na+ gain should be removed during HD. We investigate to determine the ranges of the sodium gradient (SG) between the dialysate sodium concentration (DNa) and serum sodium concentration (SNa) in hemodialysis (HD) patients and to examine the relationships between HD parameters over a one year period. Design and Method: Fifty-five clinically stable HD patients, who had been on HD >2 years were enrolled. Monthly HD ultrafiltration (UF) amount, systolic blood pressure (SBP), frequency of intradialytic hypotension (IDH) and laboratory data were collected and 12-month means were subjected to analysis. The SG was calculated by subtracting SNa from prescribed DNa. Results: The mean number of anti-hypertensive drugs being taken was 1.6 ± 1.2. In the 55 patients, SNa values ranged from 130 to 142 mEq/L and the mean CV of SNa was 1.5 ± 0.5%. Mean SG values were 1.5 ± 3.3 mEq/L (range -5.6∼9.1). Significant positive correlations were observed between DNa and SG. In addition, significant positive correlations were noted between mean UF amounts. On the other hand, no relationship was observed between SG was positively related to DNa and the frequency of IDH. A higher SG was associated with larger UF amounts and SBP reduction during HD. The percentages of patients with a SG > 3 mEq/L increased as DNa increased. On the other hand, SG was not found to be associated with SNa or pre-HD SBP. Conclusions: DNa appears to cause a significant increase in SG, and this seems to be related to HD parameters, such as, UF amount and IDH. Numbers of anti-hypertensive drugs tended to be less in patients with a SG of > 3 mEq/L, which might have been due in part to the adjustment of DNa according to BP status.

FP641COMPARATIVE ANALYSIS OF DIAGNOSTIC METHODS FOR VOLUME STATUS ESTIMATION AND INTRADIALYTIC HYPOTENSION PREVENTION IN MAINTENANCE HAEMODIALYSIS PATIENTS

INTRODUCTION AND AIMS: To estimate volume status in maintenance haemodialysis (HD) patients by cardio-thoracic ratio (CTR) method, serum level of N-terminal brain natriuretic peptide (NTpro-BNP), colapsibility index (CI) of inferior vena cava method and by multifrequency bioimpendance analysis (BIA). We also wanted to make a correlation of these methods and to perform a dry weight correction according to the multifrequency BIA results of patient's volume status. According to that intervention we expected to decrease a number of patients with symptomatic intradialytic hypotension (IDH). METHODS: 128 patients on maintenance HD were tested for eligibility in Clinical Hospital Center Rijeka, Croatia, and 65 of them were enrolled in the study. According to the frequency of IDH patients were divided in two groups: 38 patients with frequent symptomatic IDH, and 27 patiens without frequent symptomatic IDH. Volume status was estimated in all patients by four methods: CTR, NTpro-BNP, multifrequency BIA and CI of inferior vena cava, at the beginning of the study and after six months. During a follow up period, dry weight of the patients was corrected by multifrequency BIA after one and three months, respectively. Results of volume status estimated by all four methods were correlated, and also was a frequency of symptomatic IDH and the beginning and at the end of the study. RESULTS: The mean age of the patiens was 64, 98 ± 11, 73 years, range from 38 to 85 years, and 35 (53, 85%) were men. The most common underlying renal disease was diabetic nephropathy in 19 (29%) patients. Comparative analysis of the volume status estimation by CTR, multifrequency BIA, IK of inferior vena cava, and NTproBNP indicated a significant correlation (at the beginning of the study and after six months). The number of symptomatic IDH in 38 (58%) patients decreased to the 11 (17%) patients at the end of follow up (p<0, 001). Risk factors for development of symptomatic IDH were older age (P=0, 041), and diabetes (p<0, 001). CONCLUSIONS: There is a great incidence of symptomatic IDH in the patients on the maintenance HD. The interdialytic weight gain, and the number of symptomatic IDH decreased by dry weight correction according to the multifrequency BIA. Comparative analysis of four methods for volume status estimation indicates a good correlation. Multifrequency BIA is objective, fast, non-invasive, without X-ray emission and highly reproducible method which could be used for volume status estimation and symptomatic IDH prevention in maintenance HD patients.

Intradialytic hypotension and risk of cardiovascular disease.

Patients undergoing hemodialysis have an elevated risk of cardiovascular disease-related morbidity and mortality compared with the general population. Intradialytic hypotension (IDH) is estimated to occur during 20%-30% of hemodialysis sessions. To date, no large studies have examined whether IDH is associated with cardiovascular outcomes. This study determined the prevalence of IDH according to interdialytic weight gain (IDWG) and studied the association between IDH and outcomes for cardiovascular events and mortality to better understand its role. This study retrospectively examined records of 39,497 hemodialysis patients during 2007 and 2008. US Renal Data System claims and dialysis provider data were used to determine outcomes. IDH was defined by current Kidney Disease Outcomes Quality Initiative guidelines (≥20 mmHg fall in systolic BP from predialysis to nadir intradialytic levels plus ≥2 responsive measures [dialysis stopped, saline administered, etc.]). IDWG was measured absolutely (in kilograms) and relatively (in percentages). IDH occurred in 31.1% of patients during the 90-day exposure assessment period. At baseline, the higher the IDWG (relative or absolute), the greater the frequency of IDH (P<0.001). For all-cause mortality, the median follow-up was 398 days (interquartile range, 231-602 days). Compared with patients without IDH, IDH was associated with all-cause mortality (7646 events; adjusted hazard ratio, 1.07 [95% confidence interval, 1.01 to 1.14]), myocardial infarction (2396 events; 1.20 [1.10 to 1.31]), hospitalization for heart failure/volume overload (8896 events; 1.13 [1.08 to 1.18]), composite hospitalization for heart failure/volume overload or cardiovascular mortality (10,805 events; 1.12 [1.08 to 1.17]), major adverse cardiac events (MACEs; myocardial infarction, stroke, cardiovascular mortality) (4994 events, 1.10 [1.03 to 1.17]), and MACEs+ (MACEs plus arrhythmia or hospitalization for heart failure/volume overload) (12,221 events; 1.14 [1.09 to 1.19]). IDH was potently associated with cardiovascular morbidity and mortality. Clinical trials to ascertain causality are needed and should consider reduction in IDWG as a potential means to reduce IDH.