Intradialytic Blood Pressure Research Articles

Accuracy of Peridialytic, Intradialytic, and Scheduled Interdialytic Recordings in Detecting Elevated Ambulatory Blood Pressure in Hemodialysis Patients

Current recommendations suggest the use of ambulatory blood pressure monitoring (ABPM) as the gold standard for hypertension diagnosis and management in hemodialysis patients. This study assesses the accuracy of peridialytic, intradialytic, and scheduled interdialytic recordings in detecting abnormally elevated 44-hour interdialytic blood pressure (BP). Diagnostic test study. 242 Greek hemodialysis patients who successfully underwent ABPM. Ambulatory BP was used as the reference method to evaluate the accuracy of the following BP metrics: predialysis and postdialysis BP, intradialytic BP, intradialytic plus pre/postdialysis BP, and scheduled interdialytic BP (on an off-dialysis day at 8:00 am, 8:00 pm, and their average). 44-hour ambulatory systolic BP/diastolic BP (SBP/DBP)≥ 130/80 mm Hg. The 44-hour SBP/DBP levels differed significantly from predialysis and postdialysis BP but showed no or minor differences compared with the other BP metrics. Bland-Altman plots showed an absence of systematic bias for all metrics but large between-method difference and wider 95% limits of agreement for predialysis and postdialysis BP compared with intradialytic, intradialytic plus pre/postdialysis, and averaged scheduled interdialytic BP. The sensitivity/specificity and κ-statistic for diagnosing 44-hour SBP≥ 130 mm Hg were low for predialysis (86.5%/38.6%, κ-statistic = 0.27) and postdialysis BP (63.1%/73.3%, κ-statistic = 0.35), but better for intradialytic BP (77.3%/76.2%, κ-statistic = 0.53), intradialytic plus pre/postdialysis BP (76.6%/72.3%, κ-statistic = 0.49), and scheduled interdialytic BP (87.9%/77.2%, κ-statistic = 0.66). In receiver operating characteristic (ROC) analyses, the areas under the curve (AUC) of predialysis SBP (AUC = 0.723) and postdialysis SBP (AUC = 0.746) were significantly lower than that of intradialytic SBP (AUC = 0.850), intradialytic plus pre/postdialysis SBP (AUC = 0.850), and scheduled interdialytic SBP (AUC = 0.917) (z test, P< 0.001 for all pairwise comparisons). Similar observations were made for DBP. Typical home BP data were not obtained, and no assessment was obtained of the reproducibility of the examined metrics over time. Intradialytic, intradialytic plus pre/postdialysis, and scheduled interdialytic BP measurements were more accurate in detecting elevated 44-hour BP than predialysis and postdialysis BP. Averaged intradialytic BP recordings or scheduled readings at the off-dialysis day appear to be promising approaches to the diagnosis of elevated BP in hemodialysis.

Effect of various dialysis modalities on intradialytic hemodynamics, tissue injury and patient discomfort in chronic dialysis patients: design of a randomized cross-over study (HOLLANT)

BackgroundFrom a recent meta-analysis it appeared that online post-dilution hemodiafiltration (HDF), especially with a high convection volume (HV-HDF), is associated with superior overall and cardiovascular survival, if compared to standard hemodialysis (HD). The mechanism(s) behind this effect, however, is (are) still unclear. In this respect, a lower incidence of intradialytic hypotension (IDH), and hence less tissue injury, may play a role. To address these items, the HOLLANT study was designed.MethodsHOLLANT is a Dutch multicentre randomized controlled cross-over trial. In total, 40 prevalent dialysis patients will be included and, after a run-in phase, exposed to standard HD, HD with cooled dialysate, low-volume HDF and high-volume HDF (Dialog iQ® machine) in a randomized fashion. The primary endpoint is an intradialytic nadir in systolic blood pressure (SBP) of < 90 and < 100 mmHg for patients with predialysis SBP < 159 and ≥ 160 mmHg, respectively. The main secondary outcomes are 1) intradialytic left ventricle (LV) chamber quantification and deformation, 2) intradialytic hemodynamic profile of SBP, diastolic blood pressure (DBP), mean arterial pressure (MAP) and pulse pressure (PP), 3) organ and tissue damage, such as the release of specific cellular components, and 4) patient reported symptoms and thermal perceptions during each modality.DiscussionThe current trial is primarily designed to test the hypothesis that a lower incidence of intradialytic hypotension contributes to the superior survival of (HV)-HDF. A secondary objective of this investigation is the question whether changes in the intradialytic blood pressure profile correlate with organ dysfunction and tissue damage, and/or patient discomfort.Trial registrationRegistered Report Identifier: NCT03249532# (ClinicalTrials.gov). Date of registration: 2017/08/15.

Serum sodium variation is a major determinant of peridialytic blood pressure trends in haemodialysis outpatients

Intradialytic hypotension (IDH) and peridialytic blood pressure (BP) trends are associated with morbidity and mortality in haemodialysis (HD) patients. We aimed to characterise the respective influence of volume status and small solutes variation on peridialytic systolic BP (SBP) trends during HD. We retrospectively analysed the relative peridialytic SBP decrease in 647 prevalent outpatients attending for their mid-week session with corresponding pre- and post-HD bioelectrical impedance analysis. Mean SBP decreased by 10.5 ± 23.6 mmHg. Factors positively associated with the relative decrease in SBP were: serum sodium (Na) decrease, body mass index, serum albumin, dialysis vintage, ultrafiltration rate and urea Kt/V (p < 0.05 for all). Antihypertensive medications and higher dialysate calcium were negatively associated with the relative decrease in SBP (p < 0.05 for both). Age had a quadratic relationship with SBP trends (p < 0.05). Pre-HD volume status measured by extracellular to total body water ratio was not associated with SBP variation (p = 0.216). Peridialytic SBP trends represent a continuum with serum Na variation being a major determinant while volume status has negligible influence. Middle-aged and overweight patients are particularly prone to SBP decline. Tailoring Na and calcium dialysate concentrations could influence haemodynamic stability during HD and improve patient experience and outcomes.

Short-term Individualized Dialysate Cooling in Chronic Hemodialysis: Therapeutic benefits for Patients and A favorite choice for Nephrologists

Background: Intra-dialytic hypotension (IDH) and pruritus are frequent and distressing complications during hemodialysis; moreover, they are associated with adverse outcomes. The aim of the work: The current work aimed to investigate the effect of applying individualized cool dialysate (ICD) on IDH, dialysis adequacy, pruritus and its acceptance by both patient and nephrologists. Patients and Methods: This is a non-randomized single center study that was conducted at Al-Azher nephrology and dialysis unit. The study was carried out over a period of fvie weeks. Core body temperature (CBT) and dialysis adequacy (by Kt/v) were measured. Patients who fulfilled the inclusion and exclusion criteria underwent hemodialysis for six consecutive sessions at dialysate temperature of 37°C, followed by another six consecutive sessions at ICD temperature (0.5 oC below CBT). Blood pressure (BP) measurements, episodes of hypotension, pruritus score, patients and nephrologist questionnaire were collected during both standard and cool phases. Results: The study included 50 patients, the mean age 51.10±11.57 years, and males constituted 64% . The implementation of ICD has been associated with a significant reduction in IDH episodes (p <0.001). The lowest intra-dialytic and post-dialytic BP measurements were statistically higher during cool phase. There was a significant reduction in pruritus VAS score during cool phase (p <0.001), whereas Kt/v and ultrafiltration rate did not statistically differ between both phases. ICD was well tolerated by patients; although 60% of them experienced cold sensation that warranted no intervention. Nephrologists (n=20) trusted in cool dialysate as an effective intervention for IDH management. However, a proportion of them (60%) had a concern about patient tolerability. Conclusion: ICD is a well-tolerated intervention that is universally applied without additional cost. It improves hemodynamic instability and pruritus during hemodialysis treatment without negative impact on dialysis adequacy. It is accepted by nephrologists as an effective tool in stabilizing hemodynamic instability during dialysis treatment.

BLOOD PRESSURE DURING HEMODIALYSIS AS PREDICTOR OF MORTALITY IN END-STAGE RENAL DISEASE PATIENTS

Objective: High blood pressure (BP) and consequential cardiovascular complications remain the leading cause of death in hemodialysis (HD) patients. Aim of this study is to link BP variations during HD with a 1 year mortality. Design and method: We conducted a cohort study in tertiary reference dialysis center. Patients undergoing HD were enrolled. Systolic, diastolic and mean arterial BP were measured before, every hour during and after HD procedure. These patients were observed for 12 months and mortality rate was evaluated. Mean values of measurements were compared across the groups. Furthermore, these measurements were included in univariate and multivariate regression analysis, determining their potency to predict 1 year mortality. Results: Study enrolled 99 patients. Mean age of patients was 58.7 ± 14.4 years, more than a half of them were men 51 (51.5%) with median time on HD for 4,5 [2,0–8,5] years. Mortality rate was 15.2 % (n = 15). All of the BP measurements were significantly lower in deceased group, except of BP before HD. (Table 1). Univariate regression analysis revealed that all of these pressures were linked to 1 year mortality, however, after application of stepwise forward selection model in multivariate analysis the most potent predictor was eluded to be MAP of the 1st HD hour (OR CI95% p), tripling the risk of mortality per every decrease of 10mmHg. However, the difference in precipitated risk of mortality for 2nd h, 3rd h and post HD MAP was minimal. Conclusions: One year mortality in HD patients is substantial. Blood pressure during and post HD is a more potent predictor of mortality than a blood pressure measured before the procedure. Further studies should investigate the application of intradialytic BP for the timely intervention.

High Ultrafiltration Increasing Intradialytic Blood Pressure on Hemodialysis Patients

The increase in blood pressure when the patient is undergoing hemodialysis is experienced by patients with intradialytic hypertension. This condition can be very dangerous for the patient, must be prevented and needs to be controlled. Prevention can be done by controlling variables that can affect intradialytic blood pressure, including ultrafiltration during hemodialysis. This study aims to analyze the relationship between ultrafiltration (ultrafiltration goal, ultrafiltration rate) and intradialytic blood pressure. This research was a descriptive-analytic study with a cross-sectional design, with 112 samples at two centres of dialysis in Semarang. Data were analyzed using the Spearman Rho. The finding obtained showed that ultrafiltration goal (UFG) and ultrafiltration rate (UFR) correlated with intradialytic blood pressure (systolic, diastolic and mean arterial pressure). The magnitude of UFG an associated with increase in intradialytic systolic (p=0,024; r=0,213), increase in intradialytic diastolic (p=0,007; r=0,252) and increase in mean arterial pressure (p=0,016; r=0,227). High UFR is associated with with increase in intradialytic systolic (p=0,037; r=0,211), increase in intradialytic diastolic (p=0,001; r=0,320) and increase in mean arterial pressure (p=0,034; r=0,200). Determination of ultrafiltration during hemodialysis must be done carefully and precisely to prevent an increase in intradialytic blood pressure.

A DIFFERENCE IN INTRADIALYTIC BLOOD PRESSURE IN CHRONIC RENAL FAILURE PATIENTS WITH INTERDIALYTIC WEIGHT GAINS&gt; 5% AND &lt;5% IN THE HEMODIALYSIS ROOM AT RSD MANGUSADA, BADUNG REGENCY

Background: Hemodialysis, which is one of the therapies performed on patients with kidney failure when the kidneys are unable to function or have malfunctioned. Although hemodialysis is classified as safe and beneficial for patients, it does not mean that it does not have side effects, namely IDWG> 5% and <5% which make changes in intradialytic blood pressure. Objective: This study aimed at determining the differences between intradialytic blood pressure in chronic kidney failure patients with IDWG> 5%. and <5% in the hemodialysis room at RSD Mangusada Badung. Method: The study had been done with a comparative analytic design with a cross-sectional approach. The total samples were 58 people with the incidental sampling technique. Data were collected using a digital weight scale and a mercury sphygmomanometer. Data were analyzed using the Mann-Whitney test. Results: The results of the study with IDWG> 5% with the mean systolic intradialytic blood pressure of 101.79 mmHg and diastolic mean 75.43 mmHg and IDWG 5% and <5% obtained a p-value of 0.001. Conclusion: There was a difference in intradialytic blood pressure in chronic renal failure patients with IDWG> 5% and <5% in the hemodialysis room at RSD Mangusada Badung. The recommendations of this study are expected to be input for nurses to always provide education about dietary patterns related to IDWG to minimize intradialytic complications

Predialytic versus Intradialytic Nutrition: A Study to Assess Effects on Intradialytic Blood Pressure, Dialysis Adequacy, and Urea Removal

Background: Provision of oral protein in hemodialysis (HD) is desirable due to improved compliance to protein requirements and better nutritional status, but the risks of hypotension and underdialysis need to be considered. This study compared 2 different timings for administering oral nutritional supplements (ONS), predialysis and mid-dialysis, with respect to hemodynamics, dialysis adequacy, urea removal, and tolerability. Methods: This single-center, prospective crossover study analyzed 72 stable patients with ESRD on twice a week maintenance HD with a mean age of 38.7 (±11.2) years and a dialysis vintage of 28.2 (±13.1) months. In the first week, all the patients received ONS (450 kcal energy, 20 g protein) 1 h prior to start of dialysis (group 1) and in the next week, the supplement was administered after 2 h of start of dialysis (group 2), with a predialysis fasting period of at least 3 h in both groups. Blood pressures, serum, and spent dialysate samples were collected and nausea occurrence was noted by severity. Results: Predialytic intake (group 1) was associated with higher predialysis and 1st hour blood urea, dialysis adequacy, and urea removal than group 2. Both groups achieved mean Kt/V > 1.2, and the occurrence of symptomatic hypotensive episodes and nausea was not significantly different between the groups. On repeated measures ANOVA, changes in blood urea over time showed significant group effect. Conclusions: Predialytic supplementation was associated with better dialysis adequacy and urea removal than intradialytic supplementation. However, both timings were equally tolerated and not associated with underdialysis.

Does regular resistance exercise improve resting and intradialytic pain and haemodynamic measures in sedentary chronic haemodialysis women?

Pain is one of the major problems in haemodialysis patients. Regular resistance exercise (RE), as an effective lifestyle modification, may play a role in reducing pain through changes in blood pressure (BP). Therefore, we aimed to evaluate the effect of RE training on pain, BP, and heart rate. In a randomised controlled trial, eighteen sedentary women completed the study in RE (n=10) or control (n=8) groups. In the exercise group, the patients had a circuit RE program in non-dialysis days, two times a week, for six weeks. The RE protocol consisted of six exercises performing with 10 repetitions at 50-60% of 1-repetition maximum. Resting and intradialytic pain threshold (algometer using a 1 kg pressure load), BP, and heart rate were measured 48 h before and after the intervention. There were no significant differences from pre- to post-intervention, or between the groups regarding pain threshold, systolic and diastolic BP, and heart rate at rest and during the haemodialysis process (P&gt;0.05). Although the 6-week low-intensity RE training in non-dialysis days was safe for chronic haemodialysis women, it could not change resting and intradialytic pain and hemodynamic measures.

Intradialytic systolic blood pressure variation can predict long-term mortality in patients on maintenance hemodialysis.

It is unclear which time-points of intradialytic blood pressure (BP) best predict prognosis. Thus, it is important to assess the association between different time-points of intradialytic BP and prognosis in clinical practice. We recruited patients who underwent hemodialysis from January 2014 to June 2014. Data about dialysis were collected, including intradialytic BP. Cox regression analysis was performed to examine the association between different time-points of intradialytic BP and clinical events, with a follow-up through December 31, 2019. The primary endpoint was all-cause mortality. A total of 216 patients were recruitedand 62 (30.7%) patients died (6.1 per 100-person year)during the follow-up. Intradialytic SBP varied greatly in fatalities. Univariate and multivariate Cox regression models indicated that the adjusted hazard ratio for death was 1.80 and 5.06 when intradialytic systolic blood pressure (SBP) variation was analyzed in increments of 20mmHg. Furthermore, we divided intradialytic SBP variation into three categories: < 15mmHg, 15 ~ 30mmHg, ≥ 30mmHg. Kaplan-Meier analysis indicated that both all-cause mortality and cardiovascular mortality increased significantly for patients with intradialytic SBP variation over 30mmHg (P = 0.006 and 0.021). Univariate and multivariate Cox regression models indicated that the adjusted hazard ratio for death was 3.78 and 12.62 as intradialytic SBP variation ≥ 30mmHg vs. intradialytic SBP variation < 15mmHg. Intradialytic SBP variation, rather than BP of specific intradialytic time-points, has the potential to predict long-term mortality in hemodialysis patients. BP stability is crucial for patients' prognosis.

Paradoxical Association Between Intradialytic Blood Pressure Change and Long-Term Mortality with Different Levels of Interdialytic Weight Gain.

BackgroundA greater interdialytic weight gain (IDWG) implies a greater ultrafiltration rate, which might lead to hemodynamic instability and intradialytic blood pressure (BP) change in hemodialysis patients. However, current studies have not explicated the impact of IDWG on the association between intradialytic BP changes and prognosis, especially in patients without cardiac dysfunction and diabetes. In this study, we aimed to explore the relationship between absolute intradialytic BP changes and mortality with different IDWG levels.MethodsA total of 204 hemodialysis patients (without cardiac dysfunction and diabetes) were included in this prospective observation study, with a mean follow-up of 55.32±20.99 months. Initially, we collected IDWG, IDWG% (percentages according to dry weight), and pre-/post-BPs of 36 consecutive dialysis sessions during three months enrollment. And the average value of them was defined as baseline value. Patients were divided into 3 cohorts according to IDWG% tertiles (<3.3%, 3.3%–4.6%, ≥4.6%). Comparisons between different tertiles were analyzed.ResultsCompared to the low IDWG% group (tertile 1, T1), patients of high IDWG% group (tertile 3, T3) were younger, had higher ultrafiltration rate, less residual kidney function, lower BMI and dry weight, longer dialysis vintage and higher N terminal pro B type natriuretic peptide levels (P<0.05). Correlations were found between IDWG% and intradialytic BP changes. Kaplan–Meier analysis and multivariate Cox regression model adjusted for demographic data, dialysis information and predialysis BPs indicated that greater absolute intradialytic BP changes were associated with worse prognosis in T1 group (P<0.05). While in T3 group, less absolute intradialytic BP changes were associated with higher mortality (P<0.05).ConclusionThere is a paradoxical association between absolute intradialytic BP changes and long-term mortality with different IDWG levels. Both BP stability and volume balance are crucial to patients’ prognosis.

Characteristics of bioimpedance-determined fluid shifts according to intradialytic blood pressure difference

This study was designed to identify the fluid spaces that are most changed during ultrafiltration (UF) according to intradialytic blood pressure (BP) difference. BP data were collected five times (before hemodialysis [HD] and 1–4 h of HD). Intradialytic BP difference was calculated as the highest minus lowest of these BP measurements. Intradialytic systolic BP (SBP) difference over 20 mm Hg and diastolic BP (DBP) difference over 10 mm Hg were defined as wide intradialytic SBP difference (SYS-W) and DBP difference (DIA-W), respectively. We measured the various fluid spaces before HD and 1–4 h of HD, and 30 min after HD using a portable, whole-body bioimpedance spectroscopy (BIS). In this study, 85 prevalent patients aged over 18 years with a fixed dry weight (65.38 ± 12.45 years, 54.18% men, 52.50% patients with diabetes), undergoing HD had participated. 1) Mean relative reduction of extracellular water (ECW) was significantly higher in SYS-W than in narrow intradialytic SBP difference (SYS-N) patients from 1 h to 30 min after HD. 2) Mean relative reduction of intracellular water (ICW) was significantly lower in DIA-W than in narrow intradialytic DBP difference (DIA-N) patients from 1 h to 30 min after HD. 3) ECW of patients with SYS-W was significantly lower than that of patients with SYS-N. Patients with SYS-W have the characteristics of fluid shifts in which reduction of ECW was steeper than patients with SYS-N whereas fluid shifts of ICW were lower in patients with DIA-W than patients with DIA-N.

Pro-inflammatory cytokines as potential predictors for intradialytic hypotension

Background Intradialytic hypotension (IDH) is a common complication in maintaining hemodialysis (MHD) patients. Immune activation might be part of the mechanisms. However, the association between pro-inflammatory cytokines and blood pressure (BP) has not been deeply explored. So we aim to evaluate the potential role of pro-inflammatory cytokines in IDH. Methods MHD patients starting hemodialysis before January 2016 were enrolled in our retrospective study. Patients' characteristics, laboratory results, and intradialytic BP were collected. IDH was defined as nadir systolic BP ≤ 90 mmHg during hemodialysis. The definition of IDH group was that those who suffered from more than one hypotensive event during one month after the enrollment (10% of dialysis treatments). Spearman correlation analysis and logistic regression were employed to explore the relationship between pro-inflammatory cytokines and IDH. Results Among 390 patients, 72 were identified with IDH (18.5%). High levels of serum tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) were observed in the IDH group (p < 0.001). Both TNF-α and IL-1β positively correlated with predialysis BP (p < 0.01). Receiver operating characteristic curve (ROC) analysis was used to evaluate the diagnostic accuracy of serum IL-1β and TNF-α for IDH. The area under the curve of IL-1β was 0.772 (95% CI: 0.708-0.836, p < 0.01), and that of TNF-α was 0.701 (95% CI: 0.620-0.781, p < 0.01). After adjusting for patients' characteristics, biochemical parameters, comorbid conditions, predialysis BP, and medications, elevated TNF-α and IL-1β were still risk factors for IDH. Conclusion Pro-inflammatory cytokines (TNF-α and IL-1β) could be potential predictors for IDH.

Evaluating the effect of intradialytic exercise on blood pressure, inflammatory markers and dialysis adequacy

Introduction: In spite of widely accepted idea that exercise is beneficial in dialysis, it is not easy to incorporate an exercise program into routine clinical practice of these patients. Objectives: The present study was conducted to evaluate the effects of exercise on hemodialysis patients. Patients and Methods: In this non-pharmacologic clinical trial, a total of 49 clinically stable hemodialysis patients were enrolled in the study and were randomly allocated into two groups; the intervention group (n=27) and the control group (n=22). The intervention group conducted at least 30 minutes of cycling during each hemodialysis session for six months. Intradialytic blood pressure, high-sensitivity C-reactive protein (hs-CRP) blood levels and dialysis adequacy were estimated before and after dialysis. Results: At the end of the 6-month study period, a significant reduction in systolic and diastolic blood pressure in all patients of the intervention group (P&lt;0.05) was detected. Although the dialysis quality increased more than 1.2, it was not statistically significant. Moreover hs-CRP was decreased in the exercise group at the end of the study, while these outcomes were not statistically significant too. Conclusion: Intradialytic exercise can lead to a significant reduction in systolic and diastolic blood pressure in hemodialysis patients. Trial registration: This randomized controlled trial was registered in the Iranian Registry of Clinical Trials (#IRCT2015092324152N1, https://irct.ir/trial/20465, ethical code; ARAKMU.REC.1393.168.1).

High magnesium dialysate does not improve intradialytic hemodynamics or abrogate myocardial stunning.

Hemodialysis (HD) induces myocardial stunning and is associated with adverse cardiovascular outcomes. Intradialytic hypotension is a modifiable determinant of myocardial stunning. Magnesium (Mg) is reported to be valuable in maintaining intradialytic blood pressure, which potentially would protect against demand myocardial ischemia. This study aimed to compare high vs. low dialysate Mg effects on intradialytic hemodynamics and HD-induced myocardial stunning. Twenty stable prevalent HD patients entered a randomized cross-over trial of low (0.5 mmol/L) vs. high (1.0 mmol/L) dialysate Mg. Patients were studied after 2 weeks of standard HD with each Mg concentration. Serial echocardiography assessed myocardial stunning, measured by left ventricular regional wall motion abnormalities (RWMAs). Continuous intradialytic hemodynamics were measured noninvasively using thoracic bioimpedance. Median predialysis serum Mg was higher with high dialysate Mg (1.45[1.29-1.55] vs. 1.03[0.98-1.1] mmol/L, P < 0.0001). There was no significant difference in maximum intradialytic reduction in systolic BP. There was no significant difference in stroke volume, total peripheral resistance, and cardiac output. Overall ventricular global longitudinal strain (GLS) (as a sensitive marker of contractile function) was higher before dialysis in high Mg group, but there was no difference in GLS at peak stress. However, we showed a significant correlation between Mg changes and GLS changes, r = -0.47, P = 0.02. There was no difference in mean number of peak stress RWMAs per patient (4.0 ± 2.2 vs. 4.3 ± 2.9, P = 0.5). Ultrafiltration volume, a critical determinant of stunning, was not different between high and low dialysate Mg studies (1.35[0-3.3] vs. 1.5[0-2.8], P = 0.49). Manipulation of magnesium by altering dialysate magnesium concentration does not influence intradialytic hemodynamic response or HD-induced myocardial stunning in the short term. However, decreasing Mg changes appears to decrease GLS changes.

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.

Predictive modeling of blood pressure during hemodialysis: a comparison of linear model, random forest, support vector regression, XGBoost, LASSO regression and ensemble method

BackgroundIntradialytic hypotension (IDH) is commonly occurred and links to higher mortality among patients undergoing hemodialysis (HD). Its early prediction and prevention will dramatically improve the quality of life. However, predicting the occurrence of IDH clinically is not simple. The aims of this study are to develop an intelligent system with capability of predicting blood pressure (BP) during HD, and to further compare different machine learning algorithms for next systolic BP (SBP) prediction. MethodsThis study presented comprehensive comparisons among linear regression model, least absolute shrinkage and selection operator (LASSO), tree-based ensemble machine learning models (random forest [RF] and extreme gradient boosting [XGBoost]), and support vector regression to predict the BP during HD treatment based on 200 and 48 maintenance HD patients containing a total of 7,180 and 2,065 BP records for the training and test dataset, respectively. Ensemble method also was computed to obtain better predictive performance. We compared the developed models based on R2, root mean square error (RMSE) and mean absolute error (MAE). ResultsWe found that RF (R2=0.95, RMSE=6.64, MAE=4.90) and XGBoost (R2=1.00, RMSE=1.83, MAE=1.29) had comparable predictive performance on the training dataset. However, RF (R2=0.49, RMSE=16.24, MAE=12.14) had more accurate than XGBoost (R2=0.41, RMSE=17.65, MAE=13.47) on testing dataset. Among these models, the ensemble method (R2=0.50, RMSE=16.01, MAE=11.97) had the best performance on testing dataset for next SBP prediction. ConclusionsWe compared five machine learning and an ensemble method for next SBP prediction. Among all studied algorithms, the RF and the ensemble method have the better predictive performance. The prediction models using ensemble method for intradialytic BP profiling may be able to assist the HD staff or physicians in individualized care and prompt intervention for patients’ safety and improve care of HD patients.

The effect of foot massage in lowering intradialytic blood pressure at Hemodialysis Unit in Indonesian Hospital

ObjectiveTo determine the effect of foot massage on reducing blood pressure in patients with intradialytic hypertension. MethodThis study is a randomized controlled trial (RCT). Subjects were 32 hemodialyses (HD) patients randomly allocated into two groups: the control group and the intervention group. Foot massage was performed three times in intradialytic phase for 5–10 min in the first, second, and third HD hours. Measurement of blood pressure (BP) used portable sphygmomanometer. The measurement was conducted every hour. ResultsThere is a different effect of foot massage on systolic and diastole blood pressure between the control group and intervention group with p < 0.05. The difference in median value for systolic blood pressure between the two groups was 25 mmHg, and diastole was 10 mmHg. ConclusionThe foot massage is beneficial in controlling intradialytic hypertension and can be applied in the management of hemodialysis patients by nurses.

Abstract TP331: The Effect of Intradialytic Blood Pressure Variability Prior to Intracerebral Hemorrhage on Outcomes

Introduction: Increased blood pressure variability (BPV) during chronic hemodialysis (HD) is associated with cardiovascular event and all-cause mortality. However, it is largely unknown whether pre-admission intradialytic BPV affects functional outcomes in patients with acute intracerebral hemorrhage (ICH). Methods: We examined consecutive patients with acute spontaneous ICH who had received HD from our prospective stroke registry between January 2012 and March 2019. Patients with premorbid modified Rankin Scale (mRS) score of 5 and patients who could not be obtained either pre-admission or post-admission blood pressure were excluded from the study. Pre-admission intradialytic BPV was quantified by systolic blood pressure successive variation (SBP-SV) from the last pre-admission dialysis record prior to ICH. Post-admission BPV during initial 24 hours was also quantified using SBP-SV. The clinical outcomes were hematoma expansion and unfavorable outcome at 3-months (mRS score of 5 to 6). Results: Of 54 ICH patients who had received HD, 45 patients were analyzed (median age, 68 years; male, 64%; non-lobar ICH, 93 %).Unfavorable outcome was observed in 26 (58%) patients.Increased pre-admission intradialytic SBP-SV was associated with only post-admission SBP-SV, but not associated with National Institute of Health Stroke Scale (NIHSS) score, hematoma volume, or hematoma expansion.In univariate analysis, both of pre- and post-admission SBP-SV were associated with unfavorable outcome. In analysis adjusting for age, NIHSS score, and hematoma volume, pre-admission SBP-SV (per SD; odds ratio, 3.70; 95% confidence interval, 1.01-13.6) was associated with unfavorable outcome, while post-admission SBP-SV was not independently associated with unfavorable outcome. Conclusions: In ICH patients who had received chronic HD, pre-admission intradialytic BPV was independently associated with unfavorable outcome after ICH, suggesting that BP control during HD may be a therapeutic target for avoiding further neurological aggravation even once ICH has occurred.

Falls in systolic blood pressure during dialysis which require no nursing intervention are associated with increased patient intra-dialytic symptom self-reporting and prolonged post-dialysis recovery times

BackgroundHaemodialysis (HD) patients may suffer symptoms during dialysis and take time to recover post HD. We wished to determine whether patients with symptomatic intra-dialytic hypotension (IDH), requiring nursing interventions, or an asymptomatic fall in systolic blood pressure (SBP) reported more symptoms during dialysis.MethodsSix hundred three HD patients completed self-reported intra-dialytic symptom questionnaires and recovery using a visual analogue scale, which were compared with their dialysis session records.ResultsTwenty-nine (4.8%) of patients suffered symptomatic IDH, and 187 (31.0%) had a fall in SBP of > 20 mmHg. Symptomatic patients had greater total symptom scores (30 (23–44) vs 23 (10–38), p < 0.05, versus asymptomatic patients, with increased low blood pressure, dizziness, cramps, palpitations and feeling cold reported (all p < 0.05). Patients with a SBP fall of > 20 mmHg had greater total scores compared with those with a SBP increase of > 10 mmHg (26 (13–38) vs 17 (7–34), p < 0.05), with more dizziness, cramps, backache, shortness of breath and headache reported (all p < 0.05). Although ultrafiltration rates were similar, HD weight loss was greater for patients with a SBP fall of > 20 mmHg (2.5 ± 1.1 vs 2.0 ± 1.3%, p < 0.05). Patients with highest symptoms scores (highest vs lowest quartile) had longer recovery times (40.3 vs 7.6% > 4 h), p < 0.001.Multivariable analysis showed that patients reporting more intradialytic symptoms had higher psychological distress thermometer scores (odds ratio (OR) 1.34 (95% confidence limits 1.26–1.44)), systolic blood pressure < 100 mmHg (OR 2.53 (1.04–6.1)), whereas symptom scores were lower for male gender (OR 0.34 (0.22–0.51)), and with increasing age (OR 0.99 (0.97–0.99)).ConclusionPatients with both symptomatic and asymptomatic IDH, self-reported more symptoms during dialysis, and those patients reporting more symptoms had longer recovery times. We found that younger, female patients, those with greater psychological distress, and lower systolic blood pressure self-reported more intra-dialytic symptoms. More attention is required to prevent falls in intra-dialytic blood pressure to improve the patient experience of HD and shorten post-dialysis recovery times.