Intradialytic Hypotension Episodes Research Articles

The Relationship between Dialysis Adequacy and Blood Pressure and Number of Intradialytic Hypotensive Episodes in Haemodialysis Patients

Dialysis adequacy is currently defined as the dose of dialysis that covers all functions of the kidney and is measured by adequate removal of harmful substances and excess fluid accumulated in the body. The aim of this study is to examine the relationship between dialysis adequacy and blood pressure, as well as the number of intradialytic hypotensive episodes in hemodialysis patients. The study included 50 patients receiving four-hour hemodialysis three times a week at Muş State Hospital. Dialysis adequacy was based on Kt/V and URR values. Demographic data were collected by face-to-face interviews with the participants. Blood pressure, Kt/V, and URR were measured before the hemodialysis session, and then the total number of intradialytic hypotensive episodes within one hemodialysis session was recorded. There was no statistically significant correlation between Kt/V and systolic and diastolic blood pressure and number of intradialytic hypotensive episodes (P>0.05). There was no statistically significant correlation between URR and systolic and diastolic blood pressure and number of intradialytic hypotensive episodes (P>0.05). Our study shows that there is no significant relationship between dialysis adequacy and blood pressure and number of intradialytic hypotensive episodes. Further research is needed to understand how these relationships may vary among patient groups with different demographic and clinical characteristics.

The effect of changes in intra-compartmental bioimpedance measurements with early intra-dialytic hypotension during haemodialysis.

Intra-dialytic hypotension (IDH) remains the commonest problem associated with routine haemodialysis treatments. Fluid shifts from intracellular(ICW) and extracellular(ECW) compartments to refill plasma volume during haemodialysis with ultrafiltration. We studied the effect of relative changes in ICW and ECW indifferent body segments using multifrequency segmental bioimpedance during haemodialysis and IDH episodes. Of 42 haemodialysis patients,16 patients (38.1%) developed IDH within the first hour of dialysis. Patients with and without early IDH were well-matched for demographics and starting bioimpedance measurements. However, after 60 min, the relative change in in ECW/ICW ratio between the non-fistula arm and leg was significantly different for the early IDH group median -1.07 (-3.33 to 0.8) versus 0.61 (-0.78 to 1.8), p < 0.05, whereas there no differences in ultrafiltration rate, relative blood volume monitoring or on-line clearance. Monitoring serial changes in fluid status in different body compartments with bioimpedance may potentially prevent IDH in the future.

Online Hemodiafiltration: A New Perspective for Patients With End-Stage Renal Disease.

Introduction Online hemodiafiltration (OL-HDF) is the most effective renal replacement therapy (RRT), which allows the enhanced removal of small and large uremic toxins by combining diffusion and convective transport of solutes. Although the goal of OL-HDF is to provide greater clearance of solutes with a preference for intermediate molecules responsible for many of the complications of chronic kidney disease (CKD), the studies reported to date and their meta-analyses are conflicting in nature and do not show a significant advantage of convective therapies on patient prognosis. Materials and methods At the Clinic of Nephrology and Dialysis, University Hospital "St. Marina", Varna, Bulgaria, 41 patients were monitored in a retrospective study for a two-year period, randomized into two groups, conducting OL-HDF after dilution and hemodialysis (HD) with the aim of studying the effect of convective therapies on the clinical outcome, the achieved quality of life, and the prognosis of the patient. Results The study found a significantly higher quality of life in patients undergoing OL-HDF with significantly higher values ​​of indicators of dialysis adequacy and nutritional status, better control of the anemic syndrome with the reduction of erythropoietin doses, significantly lower frequency of episodes of intradialytic hypotension with improved recovery, and 3.6-fold lower risk of death compared with conventional dialysis. Discussion Three major randomized controlled trials have compared survival outcomes in patients receiving HD or post-dilution OL-HDF, reporting conflicting results. Meta-analyses of the published studies have also been unable to provide a clear and definitive answer regarding the potential benefits of choosing one treatment over the other. Overall mortality, anemia, phosphate control, and small molecule clearance appear to be insufficiently influenced by the treatment method. On the other hand, cardiovascular mortality, hemodynamic stability, and clearance of middle and protein-bound molecules seem to be better in patients treated with OL-HDF. Conclusions Despite the conflicting data reported so far, OL-HDF is associated with better clinical outcome and prognosis for end-stage renal disease (ESRD) patient and undoubtedly warrants extensive future study with a view to improved quality of life in the growing dialysis population.

#201 Bedside lung ultrasound and bioimpedance spectroscopy for assessment of volume status in chronic kidney disease patients on hemodialysis

Abstract Background and Aims Fluid balance is important in patients with chronic kidney disease undergoing hemodialysis (HD). Majority of HD treatment incorporate a prescription for fluid removal targeted to patient's dry weight. Overestimation of dry weight causes hypertension, left ventricular hypertrophy and heart failure, while underestimation is responsible for chronic dehydration leading to the risk of hypotension. Both complications have a significant impact on the overall morbidity and mortality. Dry weight of the patient is usually assessed by using clinical parameters (edema, BP, JVP etc.), Biochemical parameters (BNP, ANP), Bioimpedance Spectroscopy (BIS) or IVC diameter and collapsibility on ultrasound (VCI index). The use of chest ultrasound to detect lung water has recently received growing attention in clinical research. Ultrasonographic lung comets (counting B-lines artifact) evaluate extravascular lung water and hence is considered as a useful tool to evaluate the hydration status of hemodialysis patients. This study aims to compare the efficacy of body fluid volume status and lung water assessment by clinical methods, Ultrasound chest and Bioimpedance Spectroscopy in chronic kidney disease patients on hemodialysis. Method A cross-sectional study was conducted over a period of 6 months. Dry weight of the patient was assessed by the attending nephrologist based on clinical criteria such as: weight, blood pressure, presence of edema or vascular congestion. A Longitudinal Ultrasound scan of the chest was performed using MicroMaxx Ultrasound System with patient in supine position from second to fourth intercostal space of left hemi-thorax and second to fifth intercostal space of right hemi-thorax along parasternal, midclavicular, anterior axillary and midaxillary lines of each side in a total of 28 sectors. B-lines were defined as hyperechogenic linear artifact emerging from the pleural line, up to the bottom of the screen. Pre and Post dialysis comet score was determined by calculating the total B-lines in each sector. Bioimpedance spectroscopy using Bodystat QuadScan 4000 was performed. Pre and post dialysis total body water (TBW), intracellular water (ICW), extracellular water (ECW) and residual fluid overload (ECW pre HD- ECW post HD) were recorded. Results We conducted 100 assessments on 34 patients presenting to the hospital for maintenance hemodialysis. The mean age of the study population was 54.3 + 11 years with a sex ratio (M/F) of 6:1. Mean systolic blood pressure was 141.1 + 19 mmHg and diastolic blood pressure was 83 + 9.3 mmHg with 3 episodes of intradialytic hypotension. The mean dry weight was 59.8 + 10 Kg and weight gain by clinical assessment was 2.1 + 1.5 Kg. Comet score assessed by ultrasound chest had a mean of 4.54 + 2.53 before dialysis and 1.73 ± 1.36 after dialysis. Residual fluid overload on Bio impedance spectroscopy was 1.11 ± 0.85 litre. The residual fluid overload on Bio impedance spectroscopy and lung ultrasound comet score after dialysis had a significant correlation (p value &amp;lt;0.0001). Of the 100 assessments, 40% had fluid overload after dialysis on Bio impedance and 35% had lung congestion on ultrasound chest even after achieving euvolemia according to the dry weight assessed clinically. Conclusion Lung comets on ultrasound chest and residual volume on bio impedance spectroscopy may precede the development of clinical sign and symptoms in a patient. Therefore, these methods are superior to clinical volume status assessment in chronic kidney disease patients on hemodialysis.

Usefulness of the heart rate variability test in predicting intradialytic hypotension in patients undergoing chronic haemodialysis.

Intradialytic hypotension (IDH) is the primary complication of haemodialysis (HD); however, its diverse pathophysiology and inconsistent definitions complicate its prediction. Despite attempts using the heart rate variability (HRV) test for IDH prediction, studies on its usefulness for predicting IDH diagnosed per the nadir 90 criterion are lacking. We aimed to evaluate HRV test efficacy and reproducibility in predicting IDH based on the nadir 90 criterion. Seventy patients undergoing HD participated in this multicentre prospective observational study. The HRV test was performed during non-HD periods and IDH was monitored during 12 HD sessions. IDH was diagnosed according to the nadir 90 criterion, defined as a decrease in systolic blood pressure of ≤90mmHg during HD. After monitoring, the HRV test was repeated. An HRV-IDH index was developed using multivariate logistic regression analysis employing HRV test parameters. The predictive power of the HRV-IDH index was analysed using the area under the receiver operating characteristics curve (AUROC). Reproducibility was evaluated using correlation analysis of two HRV tests on the same patient. There were 37 and 33 patients in the IDH and non-IDH groups, respectively. The HRV-IDH index predicted IDH occurrence with AUROCs of 0.776 and 0.803 for patients who had experienced at least one or repeated IDH episodes, respectively. Spearman's correlation coefficient for HRV-IDH indices was 0.859 for the first and second HRV tests. The HRV test holds promise for predicting IDH, particularly for patients with recurring IDH diagnosed based on the nadir 90 criterion.

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.

Hypereosinophilia-associated acute intradialytic hypotension: a report of three cases and literature review.

Occasionally, patients undergoing dialysis develop acute severe hypotension that requires interruption of dialysis within minutes of initiating every dialysis session. Although the underlying causes of recurrent intradialytic hypotension are evaluated extensively, including dialysis-associated allergic reactions or other possible causes, the definitive cause is sometimes missed. Dialysis is a life-sustaining procedure; therefore, prompt identification and management of the underlying cause of dialysis intolerance are crucial. Herein, we report three cases of patients undergoing dialysis who presented with hypereosinophilia-associated acute intradialytic hypotension. All three patients developed acute severe hypotension within minutes after the start of every dialysis session. The prescriptions for dialysis were changed, but episodes of intradialytic hypotension persisted. Pretreatment with methylprednisolone given intravenously before the dialysis session was also ineffective. All patients had hypereosinophilia (> 1500/μL) of different etiology. Eosinophil-lowering therapy with 0.5 mg/kg of prednisolone given orally daily was initiated, and all of them could restart dialysis without any hypotensive episodes within a few days. Our case report and literature review indicated that hypereosinophilia, regardless of its etiology, could result in severe acute hypotension shortly after the start of dialysis session. The oral administration of prednisolone daily was highly effective on hypereosinophilia-associated intradialytic hypotension, while pretreatment with intravenous corticosteroid therapy just before dialysis had no effect. Hypereosinophilia-associated acute intradialytic hypotension is an under-recognized condition; therefore, clinicians need to be aware of this clinical entity and initiate effective treatment strategies. We also provide a brief summary of previously published cases.

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

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

The Optimization of Outpatient Hemodialysis Management for Acute Kidney Injury Requiring Dialysis Patients: A Quality Improvement Study

Introduction: In 2017, the Centers for Medicare and Medicaid Services allowed survivors of hospitalized acute kidney injury requiring dialysis (AKI-D) who were ambulatory and still dependent on hemodialysis (HD) to receive treatment in outpatient dialysis facilities. This policy change generated the ongoing need to improve AKI-D care in the outpatient setting. Methods: Quality improvement study in adult patients admitted to an outpatient HD unit with the diagnosis of AKI-D. We developed a protocol to manage these patients that included: (a) multidisciplinary evaluations; (b) personalized 3-tier HD prescription for dose/ultrafiltration rate and frequency; (c) weekly assessment of kidney recovery; and (d) patient empowerment. Patient- and protocol-specific characteristics were described. We analyzed hourly HD data and protocol adherence, and relevant hemodynamic data were compared according to HD-free survival at 90 days. Results: A total of 457.3 h of HD from 9 patients under the AKI-D protocol were interrogated. Three out of 9 patients were alive and liberated from HD within the first 90 days of outpatient HD. Overall protocol adherence was 53.8% and did not differ by HD-free survival (54.5% vs. 53.7% in those that recovered vs. not). Protocol adherence was associated with fewer intradialytic hypotension events (peak to nadir blood pressure, p < 0.01), while intradialytic hypotension (pre- to post-blood pressure) occurred more frequently in patients who did not recover kidney function (p = 0.009). Conclusion: We demonstrated the feasibility of implementing a management protocol for AKI-D patients in an outpatient dialysis facility. We found that fewer episodes of intradialytic hypotension occurred when the outpatient HD management was adherent to the protocol. The feasibility of this protocol should be confirmed in other facilities, and importantly, efficacy testing to evaluate its impact on AKI-D outpatient care is necessary.

Circumferential Strain as a Marker of Vessel Reactivity in Patients with Intradialytic Hypotension.

Background and Objectives: Intradialytic hypotension (IDH) complicates 4 to 39.9% of hemodialysis (HD) sessions. Vessels' reactivity disturbances may be responsible for this complication. Two-dimensional speckle tracking is used to assess arterial circumferential strain (CS) as a marker of the effectiveness of the cardiovascular response to the reduction of circulating plasma. Materials and Methods: The common carotid artery (CCA) and common iliac artery (CIA) CSs were recorded using ultrasonography in 68 chronically dialyzed patients before and after one HD session. Results: In patients with IDH episodes (n = 26), the CCA-CS was significantly lower both before (6.28 ± 2.34 vs. 4.63 ± 1.74 p = 0.003) and after HD (5.00 (3.53-6.78) vs. 3.79 ± 1.47 p = 0.010) than it was in patients without this complication. No relationship was observed between CIA-CS and IDH. IDH patients had a significantly higher UF rate; however, they did not differ compared to complication-free patients either in anthropometric or laboratory parameters. Conclusions: Patients with IDH were characterized by lower pre- and post-HD circumferential strain of the common carotid artery. The lower CCA-CS showed that impaired vascular reactivity is one of the most important risk factors for this complication's occurrence.

Pre-Dialysis B-Line Quantification at Lung Ultrasound Is a Useful Method for Evaluating the Dry Weight and Predicting the Risk of Intradialytic Hypotension.

Intradialytic hypotension (IDH) is a frequent and well-known complication of hemodialysis, occurring in about one third of patients. An integrated approach with different methods is needed to minimize IDH episodes and their complications. In this prospective observational study, recruited patients underwent a multiparametric evaluation of fluid status through a lung ultrasound (LUS) with the quantification of B-lines, a physical examination, blood pressure, NT-proBNP and chest X-rays. The evaluation took place immediately before and at the end of the dialysis session, and the patients were divided into IDH and no-IDH groups. We recruited a total of 107 patients. A pre-dialysis B-line number ≥ 15 showed a high sensitivity in fluid overload diagnosis (94.5%), even higher than a chest X-ray (78%) or physical examination (72%) alone. The identification at the beginning of dialysis of &lt;8 B-lines in the overall cohort or &lt;20 B-lines in patients with NYHA 3-4 class are optimal thresholds for identifying those patients at higher risk of experiencing an IDH episode. In the multivariable analysis, the NYHA class, a low pre-dialysis systolic BP and a low pre-dialysis B-line number were independent risk factors for IDH. At the beginning of dialysis, the B-line quantification at LUS is a valuable and reliable method for evaluating fluid status and predicting IDH episodes. A post-dialysis B-line number &lt;5 may allow for an understanding of whether the IDH episode was caused by dehydration, probably due to due to an overestimation of the dry weight.

Prevalence of Overhydration in Patients on Maintenance Haemodialysis As Determined by Body Composition Monitor and Effects of Attaining Target Dry Weight.

Introduction: Fluid overload in chronic kidney disease (CKD) is an independent risk factor for all-cause mortality. The volume of ultrafiltrate removed during haemodialysis is usually assessed clinically. Assessment of overhydration by body composition monitor (BCM) using bioimpedance spectroscopy is an objective method. This study was conducted to identify the prevalence of overhydration in CKD patients on maintenance haemodialysis and thereby assess the effects of BCM targeted dry weight attainment.Methods: All patients included in the study were assessed for one month before enrolment for blood pressure, intradialytic events during each dialysis and BP medications. Overhydration was defined as the ratio of overhydration to extracellular water (OH/ECW) > 1.1. Overhydrated patients were brought to BCM targeted dry weight by increasing ultrafiltrate to 500mL/week more than their routine intradialytic weight gain. The effect of attaining BCM target dry weight on blood pressure and intradialytic events were analysed.Results: Out of 110 patients, overhydration was seen in 30 (27.2%); only 20 had clinically evident overhydration. Body composition monitor guided dry weight was achieved in 28 of the 30 patients after a mean duration of 20 weeks. After achieving the target dry weight, there was a significant reduction in intradialytic hypertension events (2.37 vs 1.82 events per session, p-value 0.01). Surprisingly, there was a reduction in episodes of intradialytic hypotension as well, though this did not reach statistical significance. There was a clinically significant reduction in mean systolic and diastolic blood pressures (mean of 5.7mmHg and 2.8mmHg, respectively).Conclusion: The study underlines the importance of BCM-based hydration status assessment and target dry weight attainment in better control of intradialytic events and blood pressure in patients on maintenance haemodialysis.

Intradialytic hypotension frequency is reduced by levocarnitine supplementation

Introduction: Intradialytic hypotension (IDH) is a frequent complication of hemodialysis. IDH causes intradialytic discomfort and subclinical ischemia, resulting in a higher rate of morbidity and mortality. Levocarnitine (LC) administration has been suggested for the treatment of IDH, but conflicting reports about its efficacy have been published. We describe the effect of LC supplementation in patients experiencing recurrent IDH episodes, in spite of common strategies used to prevent it. Methods: Sixteen hemodialysis patients were studied. IDH was defined as a drop in systolic blood pressure ≥20 mmHg, with or without symptoms, prompting an intervention by the dialysis staff, such as reducing/stopping ultrafiltration rate and/or fluid administration. Blood pressure was recorded for 192 hemodialysis sessions, before LC supplementation. Thereafter LC (30 mg/kg dry weight) was administered at the beginning of each hemodialysis, registering blood pressure for 384 hemodialysis treatments. The difference between the predialysis systolic blood pressure and the minimum systolic blood pressure of each hemodialysis was evaluated (∆SBP), before and after LC supplementation. Cardiac ejection fraction was also measured. Results: Predialysis and postdialysis systolic, diastolic, and mean arterial pressures did not differ before and after LC supplementation. Before LC supplementation, 36 episodes of IDH occurred (19%), while after LC supplementation, the IDH episodes were 29 during 384 hemodialysis sessions (8%; χ2 = 16.03; p = 0.0001). ∆SBP was lower after LC supplementation, even though the difference was not significant (p = 0.22). Conclusion: IDH frequency was significantly reduced by predialysis LC supplementation, which can be helpful for patients’ well-being and reduction in IDH-associated risks.

Renal Transplantation in Pure Autonomic Failure.

Renal Transplantation in Pure Autonomic Failure.

Role of Antihypertensives in End-Stage Renal Disease: A Systematic Review.

The primary goal of this research is to identify the factors of intradialytic hypertension in hemodialysis patients and stabilize blood pressure (BP) even without antihypertensive medicines. There are various treatment alternatives for lowering BP in these patients, many of which do not require extra pharmacological therapy (e.g. long, slow hemodialysis; short, daily hemodialysis; nocturnal hemodialysis; or, most effectively, dietary salt and fluid restriction in addition to the reduction of dialysate sodium concentration). These parameters provide good monitoring of BP, even with previously diagnosed hypertension. The adjustment of the extracellular volume with a low incidence of intradialytic hypotensive episodes is the most plausible explanation for this outcome.We did a systematic evaluation of all published articles since 1994 to evaluate antihypertensive drug outcomes in hemodialysis patients. All articles were searched in the English language using PubMed and Google Scholar databases. The screening techniques, study selection, data extraction procedures, and risk evaluation of bias were done using specified criteria and overseen by one of the senior writers with the application of quality assessment tools to the final articles. Data were searched using regular and MeSH (Medical Subject Headings) keywords. Although substantial developments have emerged in the medical field, there is still a significant knowledge gap in the sector, particularly when it comes to BP guidelines and therapy choices for hypertensive hemodialysis patients. Until additional data are available, we should treat hypertension in hemodialysis with the use of active pursuit of euvolemia using dry weight probing and reduction of salt excess.

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

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

Low-Dose Dopamine in the Management of Intradialysis Hypotension: A Retrospective Cohort Study in Nigeria

Introduction: Intradialytic hypotension (IDH) still remains a common finding in maintenance haemodialysis despite improvements in dialysis delivery. Measures are needed to minimise some aftermath of IDH like dialysis termination, which can impact poorly on dialysis outcome. Methods: This retrospective study assessed IDH in a low-income setting, and compared two cohorts of IDH with and without dopamine treatment. Results: Of the 416 participants, 92 (22.1%) had at least an episode of symptomatic IDH. Of these, 20 (21.7%) were treated with dopamine. Of the 2,205 sessions, 468 (21.2%) had symptomatic IDH, of which 63 (13.4%) with severe IDH were treated with dopamine. The mean age of all participants and dopamine treatment participants were 50.8 ± 9.3 years and 64.6 ± 9.5 years, respectively (P=0.001). Blood pressure (BP) reductions following dialysis were more with females (P=0.04). Dialysis dose was adequate in 7.9% and 4.2% of sessions with and without dopamine (P&lt;0.001). Improvements in glomerular filtration rate were greater in dopamine-treated sessions (P=0.03 and P=0.04, respectively). Fewer anti-hypertensives (aOR: 14.64; 95% confidence interval [CI]: 7.88–20.41), low predialysis systolic (aOR:5.59; 95% CI: 3.88–9.41), and diastolic blood pressure (aOR: 5.78; 95% CI: 4.06-9.81) were independently associated with dopamine-treated sessions. Conclusion: IDH was found in 21.2% of dialysis sessions. 13.4% with severe IDH had dopamine treatment. Participants with dopamine-treated sessions had fewer dialysis terminations and hospitalisations, and dopamine treatment improved the prescribed dialysis and gave higher dialysis doses. Considering the economic effects of dialysis termination in low-income nations, intradialytic dopamine could be very beneficial.

Boosted machine learning model for predicting intradialytic hypotension using serum biomarkers of nutrition

Intradialytic hypotension (IDH) is a serious complication of hemodialysis (HD), with an incidence of more than 20%. IDH induces ischemic organ damage and even reduces the ultrafiltration and duration of HD sessions. Frequent attacks of IDH are a risk factor for death in HD patients. Malnutrition is common in HD patients and is also associated with mortality. Although the link between IDH episodes and malnutrition has been observed in practice, it has not been supported by the data. To study the relationship, we propose a promising hybrid model called BSCWJAYA_KELM, which is a wrapper feature selection method based on a variant of the JAYA optimization algorithm (SCWJAYA) and Kernel extreme learning machine (KELM). In this paper, we verify the optimization capability of the SCWJAYA algorithm in the model by comparing experiments with some state-of-the-art methods for IEEE CEC2014, IEEE CEC2017, and IEEE CEC2019 benchmark functions. The prediction accuracy of BSCWJAYA_KELM is validated by the public datasets and the HD dataset. In the experiments on the HD dataset, 1940 HD sessions of 178 HD patients are analyzed by the developed BSCWJAYA_KELM model. The key indicators selected from vast amounts of data are serum uric acid, dialysis vintage, age, diastolic pressure, and albumin. The BSCWJAYA_KELM method is a stable and excellent prediction model that can achieve a more accurate prediction of IDH.

Association of Intradialytic Hypotension and Ultrafiltration with AKI-D Outcomes in the Outpatient Dialysis Setting.

Identifying modifiable predictors of outcomes for cases of acute kidney injury requiring hemodialysis (AKI-D) will allow better care of patients with AKI-D. All patients with AKI-D discharged to University of Virginia (UVA) outpatient HD units between 1 January 2017 to 31 December 2019 (n = 273) were followed- for up to six months. Dialysis-related parameters were measured during the first 4 weeks of outpatient HD to test the hypothesis that modifiable factors during dialysis are associated with AKI-D outcomes of recovery, End Stage Kidney Disease (ESKD), or death. Patients were 42% female, 67% Caucasian, with mean age 62.8 ± 15.4 years. Median number of dialysis sessions was 11 (6–15), lasting 3.6 ± 0.6 h. At 90 days after starting outpatient HD, 45% recovered, 45% were declared ESKD and 9.9% died, with no significant changes noted between three and six months. Patients who recovered, died or were declared ESKD experienced an average of 9, 10 and 16 intradialytic hypotensive (IDH) episodes, respectively. More frequent IDH episodes were associated with increased risk of ESKD (p = 0.01). A one liter increment in net ultrafiltration was associated with 54% increased ratio of ESKD (p = 0.048). Optimizing dialysis prescription to decrease frequency of IDH episodes and minimize UF, and close monitoring of outpatient dialysis for patients with AKI-D, are crucial and may improve outcomes for these patients.

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

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