Intradialytic Hypotension In Patients Research Articles

Risk of Intradialytic Hypotension in Hemodialysis Patients with Different Residual Urine Volume

Background: Relationship between intradialytic hypotension (IDH) and residual urine volume (RUV) in hemodialysis (HD) patients remained unclear. In the present study, we aimed to evaluate the risk of intradialytic hypotension in hemodialysis patients with different residual urine volume. Method: This work was a prospective observational study of incident and prevalent HD patients. From January 1, 2013 to February 28, 2014, patients were recruited from a single HD center of the Second Affiliated Hospital of Nanchang University. Eligible patients were categorized into three groups: group A (RUV > 400 ml/24 hours), group B (RUV of 100-400 ml/24 hours) and group C (RUV < 100 ml/24 hours). A Logistic regression model was used to examine patient characteristics associated with predictive odds of RUV with 100-400 ml/24 hours and < 100 ml/24 hours. Hazard ratio (HR) of IDH was calculated by the Cox proportional hazards model for three groups. Results: Totally, 150 HD patients were enrolled in this study, with mean follow-up of 9.9 ± 5.1 months. Older age, longer HD vintage and lower levels of hemoglobin were independently associated with RUV with 100-400 ml/24 hours, whereas thrice-weekly HD, longer HD vintage, diabetes and lower levels of phosphate were independently associated with RUV 400 ml/24 hours, even when extensive demographics, comorbidities and lab adjustments were made. Similarly, in a maximally adjusted model, risk of IDH in patients with RUV of 100-400 ml/24 hours was 2.36 times than that in those with RUV > 400 ml/24 hours (95% CI 1.75-7.47, p=0.043). Conclusion: HD patients with lower RUV may have an increased risk of presenting IDH, which suggested that preserving RUV may be conducive to preventing of IDH occurrence.

血圧低下を契機に非閉塞性腸管虚血症を発症した血液透析患者の2例

血圧低下を契機に非閉塞性腸管虚血症を発症した血液透析患者の2例

Risk of intradialytic hypotension in patients on thrice-weekly versus twice-weekly hemodialysis

Being afraid of inadequate dialysis, thrice-weekly HD has been regarded as a standard renal replacement therapy (RRT) for ESRD patients [1]. Nevertheless, twice-weekly HD remains prevalent in the developing countries and also could be found in some developed countries [2,3]. Thus far, scarce data are available for the clinical outcomes, especially intradialytic hypotension (IDH), of twice-weekly HD patients. Few studies have used a rigorous definition of IDH according to the European Best Practice Guidelines (EBPG), which defines as both a fall blood pressure and the occurrence of symptoms requiring an intervention [4].

Prevention of Intradialytic Hypotension in Patients with Acute Kidney Injury Submitted to Sustained Low-Efficiency Dialysis

Objectives: This study evaluated the effects of a protocol aiming to reduce hypotension in acute kidney injury (AKI) patients submitted to sustained low-efficiency dialysis (SLED). Methods: Patients were randomly assigned to two SLED prescriptions—control group, dialysate temperature was 37.0°C with a fixed sodium concentration [138 mEq/L] and ultrafiltration (UF) rate; and profiling group, dialysate temperature was 35.5°C with a variable sodium concentration [150–138 mEq/L] and UF rate. Results: Sixty-two SLED sessions were evaluated (34 in profiling and 28 in control). Patients (n = 31) were similar in terms of gender, age, and Sequential Organ Failure Assessment (SOFA) score. Dialysis time, dialysis dose, and post-dialysis serum sodium were similar in both groups. The profiling group had significantly less hypotension episodes (23% vs. 57% in control, p = 0.009) and achieved higher UF volume (2.23 ± 1.25 L vs. 1.59 ± 1.03 L in control, p = 0.04) when compared with control group. Conclusions: SLED protocol with modulation of dialysate temperature, sodium, and UF profiling showed similar efficacy but less intradialytic hypotension when compared with a standard SLED prescription.

Is there any role for sodium modeling in the prevention of intradialytic hypotension in patients with large interdialytic fluid gains?

Is there any role for sodium modeling in the prevention of intradialytic hypotension in patients with large interdialytic fluid gains?

Incidence and Measures to Prevent Intradialytic Hypotension in Patients on Maintenance Hemodialysis in a Tertiary Care Centre in India

Objective: Hypotension is quite common in any dialysis unit and despite significant improvements of hemodialysis techniques in the recent years; the frequency of recurrent intradialytic hypotension episodes has remained nearly unchanged. Our study is aimed to define the pathogenesis of intradialytic hypotension and attempts to describe effective measures for the hypotension prone hemodialysis patients on an individual basis. Design: This is a prospective study of 100 hemodialysis patients observed over 12 months at the Lilavati Hospital and Research Centre, Mumbai, India. Subjects with more than two episodes/month of hypotension on dialysis were diagnosed as having IDH. Results: Intradialytic hypotension was found in 18% of subjects. Incorrectly assessed ideal body weight was found to be the commonest cause of intradialytic hypotension. Volume assessment and adjusting the ideal body weight was found to be central to the problem of preventing intradialytic hypotension. Conclusion: This study shows that intradialytic hypotension is a common phenomenon, even in a tertiary care centre. Preventive strategies should be developed in each unit to decrease the future risk for intradialytic hypotension in specific patients.

Real-time three-dimensional echocardiography provides advanced haemodynamic information associated with intra-dialytic hypotension in patients with autonomic dysfunction

Real-time three-dimensional echocardiography (RT3DE) has emerged as a more accurate and effective tool for assessing left ventricular (LV) function, compared to traditional two-dimensional (2D) methods. In this study, we used this new tool to revise the controversial relationship between LV function and intra-dialytic hypotension. This study enrolled 29 intra-dialytic hypotensive patients (the IDH group) and 34 controls (the CON group) on regular maintenance haemodialysis. The RT3DE- and 2D-derived ejection fraction (EF), stroke volume index (SVI) and ratio of early transmitral inflow velocity to diastolic early tissue velocity were assessed at pre-dialysis and mid-dialysis. The intravascular volume was assessed by the inferior vena cava collapsibility index. Pre-dialysis evaluation showed no difference in RT3DE- and 2D-derived parameters between the two groups. At mid-dialysis, the IDH group had a lower 2D EF (54 +/- 9.1 versus 62 +/- 6.8% in the CON group, P < 0.001), RT3DE EF (53 +/- 6 versus 60 +/- 7% in the CON group, P < 0.001) and SVI (24.3 +/- 8 versus 30.6 +/- 12.2 mL in the CON group, P = 0.02). From pre-dialysis to mid-dialysis, the IDH group had greater decrease in the change in 2D EF (-4.8% +/- 12.6% versus 5% +/- 13.7% in the CON group, P = 0.004), RT3DE EF (-11.8 +/- 10.3 versus -3.4 +/- 11.5% in the CON group, P = 0.003) and SVI (-17.3 +/- 18.5 versus -9.2 +/- 19.8% in the CON group, P = 0.004). The calculated cardiac index change also showed a greater decrease in the IDH group (-17.8 +/- 20.2 versus -5.7 +/- 18.5% in the CON group, P = 0.02). No significant difference in the ratio of early transmitral inflow velocity to diastolic early tissue velocity, heart rate, systemic vascular resistance index or inferior vena cava collapsibility index was found between the two groups at the baseline or mid-dialysis. A lack of an increase in heart rate and the systemic vascular resistance index in the IDH group during the hypotensive episodes implies that these patients have autonomic dysfunction. Multivariate analysis showed that the RT3DE EF change of < -9.5% (odds ratio = 6, P = 0.003) and the presence of diabetes (odds ratio = 4.4, P = 0.013) had significant and independent associations with intra-dialytic hypotension. By adopting RT3DE to assess LV performance, our data demonstrated that an inadequate compensation in the LV systolic function is the main mechanism mediating the occurrence of intra-dialytic hypotension in patients with autonomic dysfunction.

L‐carnitine supplementation in the dialysis population: Are Australian patients missing out? (Review Article)

It has been widely established that patients with end-stage renal disease undergoing chronic haemodialysis therapy exhibit low endogenous levels of L-carnitine and elevated acylcarnitine levels; however, the clinical implication of this altered carnitine profile is not as clear. It has been suggested that these disturbances in carnitine homeostasis may be associated with a number of clinical problems common in this patient population, including erythropoietin-resistant anaemia, cardiac dysfunction, and dialytic complications such as hypotension, cramps and fatigue. In January 2003, the Centers for Medicare and Medicaid Services (USA) implemented coverage of intravenous L-carnitine for the treatment of erythropoietin-resistant anaemia and/or intradialytic hypotension in patients with low endogenous L-carnitine concentrations. It has been estimated that in the period of 1998-2003, 3.8-7.2% of all haemodialysis patients in the USA received at least one dose of L-carnitine, with 2.7-5.2% of patients receiving at least 3 months of supplementation for one or both of these conditions. The use of L-carnitine within Australia is virtually non-existent, which leads us to the question: Are Australian haemodialysis patients missing out? This review examines the previous research associated with L-carnitine administration to chronic dialysis patients for the treatment of anaemia, cardiac dysfunction, dyslipidaemia and/or dialytic symptoms, and discusses whether supplementation is warranted within the Australian setting.

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

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

ACE inhibitors in hemodialysis patients: Does survival improve?

ACE inhibitors in hemodialysis patients: Does survival improve?

Dialysate calcium profiling during hemodialysis: Use and clinical implications

Low dialysate calcium (LdCa) concentration is used to prevent or treat hemodialysis (HD)-induced hypercalcemia, but its use has been complicated by intradialytic hypotension in some patients. Our goal was to explore the possibility that dialysis calcium profiling (dCaP) can ameliorate intradialytic hypotension in HD patients who need to have dialysis performed with LdCa. In a randomized crossover design, eighteen HD patients underwent one four-hour HD session with LdCa of 1.25 mmol/L (LdCa group) and one four-hour HD session with LdCa of 1.25 mmol/L during the first two hours and high dCa of 1.75 mmol/L during the remaining two hours (dCaP group). After that, they underwent another four-hour HD session with medium dCa of 1.5 mmol/L (MdCa group). Before HD and at four 60-minute intervals during the HD sessions, blood pressure (BP), heart rate (HR) and noninvasive measurements of cardiac index (CI), using bioelectrical impedance, were obtained. Ionized serum calcium (iCa) also was measured before HD and at 120 and 240 minutes into the HD session. In a separate study, eight HD patients were treated for three weeks with 1.25 mmol/L dCa and three weeks with the dCaP technique described above, in random order. A three-week treatment with MdCa followed. BP and symptoms were recorded during each HD session. During the LdCa treatment the iCa values remained unchanged, whereas mean arterial pressure (MAP) and CI decreased by 16.5 +/- 8.3% and 14.2 +/- 14.6%, respectively, at the end of HD. During the first half of the dCaP treatment, iCa, MAP and CI decreased by 2.2 +/- 4.1%, 12.6 +/- 12.3%, and 9.6 +/- 13.4%, respectively, whereas during the second half of the same treatment, iCa, MAP and CI values increased by 10.2 +/- 3.3%, 7.8 +/- 7.2% and 10.8 +/- 9.1%, respectively, from the middle HD values. ANOVA showed that the time x treatment effect was significant for iCa, MAP and CI. Total peripheral resistance and HR changes were insignificant and similar among treatments. Hemodynamic effects were comparable between LdCa and MdCa treatments. Intradialytic events were reduced (P < 0.05) only with the dCaP treatment. The drop in BP observed during the last two hours of HD in both the LdCa and MdCa groups was abolished in the dCaP group. The latter was accomplished via an increase in cardiac output, due to an iCa-induced increase in myocardial contractility. Therefore, dCaP, by individualizing the dCa concentrations used and timing the switching between them, may improve intradialytic BP instability and simultaneously minimize the risk for HD patients to develop hypercalcemia.

Effect of Predialysis Verapamil on Intradialytic Blood Pressure in Chronic Hemodialysis Patients

Decreased left ventricular compliance because of hypertrophy or fibrosis may contribute to hypotension during hemodialysis. While calcium channel blockade may reduce intradialytic hypotension in patients with left ventricular hypertrophy and refractory pulmonary congestion, it is unknown whether such an effect might be seen in unselected hemodialysis patients. Verapamil (40 mg) or a placebo was given 1 hour before hemodialysis to 10 patients in a double-blind crossover study. Two 2 week verapamil periods alternated with two 2 week placebo periods. Patients received bicarbonate for either 3 hours (7 patients, high-flux, Filtral, Gambro-Hospal Inc., Williamsburg, VA) or for 4 hours (3 patients, Travenol 15.11 or CA 110, Baxter Healthcare, Deerfield, IL). Left ventricular hypertrophy was present by ultrasound in 7 of 8 patients tested and by electrocardiogram in 1 of the remaining 2. Intradialytic blood pressures were similar during the drug and placebo trials. The number of episodes of symptomatic hypotension per hemodialysis was 0.99 with verapamil and 0.93 during the placebo periods (p > 0.05). Thus, a single predialysis dosage of verapamil has no effect on intradialytic blood pressure in an unselected hemodialysis population.

Effect of Predialysis Verapamil on Intradialytic Blood Pressure in Chronic Hemodialysis Patients

Decreased left ventricular compliance because of hypertrophy or fibrosis may contribute to hypotension during hemodialysis. While calcium channel blockade may reduce intradialytic hypotension in patients with left ventricular hypertrophy and refractory pulmonary congestion, it is unknown whether such an effect might be seen in unselected hemodialysis patients. Verapamil (40 mg) or a placebo was given 1 hour before hemodialysis to 10 patients in a double-blind crossover study. Two 2 week verapamil periods alternated with two 2 week placebo periods. Patients received bicarbonate for either 3 hours (7 patients, high-flux, Filtral, Gambro-Hospal Inc., Williamsburg, VA) or for 4 hours (3 patients, Travenol 15.11 or CA 110, Baxter Healthcare, Deerfield, IL). Left ventricular hypertrophy was present by ultrasound in 7 of 8 patients tested and by electrocardiogram in 1 of the remaining 2. Intradialytic blood pressures were similar during the drug and placebo trials. The number of episodes of symptomatic hypotension per hemodialysis was 0.99 with verapamil and 0.93 during the placebo periods (p less than 0.05). Thus, a single predialysis dosage of verapamil has no effect on intradialytic blood pressure in an unselected hemodialysis population.