Intradialytic Symptoms Research Articles

Psychosocial Determinants for Self-Reported Health Status in Hemodialysis Patients: A Cohort Analysis of the CONVINCE Randomized Trial.

We investigated whether psychosocial determinants self-efficacy and social support are associated with Health-Related Quality of Life in hemodialysis patients enrolled in the CONVINCE trial. We used baseline data from the cohort of patients involved in the CONVINCE randomized trial of hemodiafiltration versus hemodialysis. Measures included age, gender, relationship status, children, housing, education, employment, comorbidities, dialysis schedules, time of first dialysis, residual kidney function, general self-efficacy and social support scores, and PROMIS measurements for health-related quality of life. Associations were analyzed using hierarchical regression. One thousand three hundred and sixty patients from CONVINCE were the cohort of interest. Mean age was 62±13.5 years (range 20-92), and 66.9% were men. Self-efficacy was a significant predictor for all health-related quality of life domains: depression (β = -0.36, p < 0.001), anxiety (β = -0.35, p < 0.001), social participation (β = 0.32, p < 0.001), cognition (β = 0.29, p < 0.001), fatigue (β = -0.29, p < 0.001), physical function (β = 0.27, p < 0.001), sleep disturbance (β = -0.23, p < 0.001), pain interference (β = 0.21, p < 0.001), pain intensity (β = -0.17, p < 0.001), interdialytic symptoms (β = -0.14, p = 0.002) and intradialytic symptoms (β = -0.14, p = 0.002). Social support was a significant predictor for cognition (β = 0.21, p < 0.001), sleep disturbance (β = -0.11, p = 0.017) and intradialytic symptoms (β =- 0.11, p = 0.02). Higher general self-efficacy scale scores are associated with improvements in cognition, depression, anxiety, social participation, fatigue, physical function, sleep disturbance, pain interference, interdialytic symptoms, pain intensity and intradialytic symptoms. Associations for self-efficacy are larger than those for social support and stronger than previously reported. It is plausible that targeted psychosocial interventions may improve health outcomes in people on hemodialysis.

#2594 Patient-reported inter- and intradialytic symptoms in HD &amp; HDF patients

Abstract Background and Aims Patients on hemodialysis (HD) experience a wide range of symptoms during and between dialysis that negatively affect their well-being. Addressing these symptoms, particularly from the patient's perspective, is a crucial component in the treatment. Our findings suggest a beneficial effect of hemodiafiltration (HDF) over hemodialysis (HD) on mortality and quality of life. This study aimed to investigate the differences in symptom severity between patients on HD and HDF. Method Patient-reported outcomes data of 1264 hemodialysis patients were extracted from CONVINCE, an international randomized controlled trial comparing high-dose hemodiafiltration with high-flux hemodialysis, including baseline and quarterly follow-up data up to 24 months. Symptoms were assessed using the CONVINCE peridialytic symptoms questionnaire covering inter- as well as intradialytic symptoms (see Table 1) with items scored between 0-100, higher scores indicating fewer symptoms. Prevalence and scores of all inter- and intradialytic symptom items at baseline and during follow-up visits were assessed and compared between HD and HDF groups. The association of changes of symptom scores over time with dialysis modality (HD vs. HDF) was assessed by Mixed Models for Repeated Measures (MMRM). Results MMRM analyses showed no significant main effects of dialysis modality on symptoms at the p &amp;lt;.05 level. However, descriptive statistics and plots indicated higher scores for most symptoms in the HDF group. The highest score differences between HDF and HD group over all timepoints were found for itchy skin (2.09 [95% CI −0.09-4.26]), numbness in hands or feet (2.03 [95% CI −0.22-4.28]), being washed out or drained (1.88 [95% CI −0.23-3.99]) and lack of appetite (1.73 [95% CI −0.03-3.50]). Plots for these symptoms can be found in Fig. 1. Furthermore, no significant interactions were found between dialysis modality and time, indicating that the rate of change in symptom scores did not differ significantly between the HDF and HD group. Conclusion No statistically significant differences in patient-reported symptoms between HDF and HD patients were found. We may not have the granularity of data to fully explore factors which may have contributed to the positive effects of HDF that have been reported previously. This might be due to the method of symptom assessment used or specific issues with perception of symptom burden. Our results highlight the complexity of symptom management in dialysis patients and underscore the need for future symptom assessments to allow for personalized treatment strategies that further optimize patient care.

The Association Between Intradialytic Symptom Clusters and Recovery Time in Patients Undergoing Maintenance Hemodialysis: An Exploratory Analysis.

Individuals receiving hemodialysis often experience concurrent symptoms during treatment and frequently report feeling unwell after dialysis. The degree to which intradialytic symptoms are related, and which specific symptoms may impair health-related quality of life (HRQoL) is uncertain. To explore intradialytic symptoms clusters, and the relationship between intradialytic symptom clusters with dialysis treatment recovery time and HRQoL. We conducted a post hoc analysis of a prospective cohort study of 118 prevalent patients receiving hemodialysis in two centers in Calgary, Alberta and Hamilton, Ontario, Canada. Adults receiving hemodialysis treatment for at least 3 months, not scheduled for a modality change within 6 weeks of study commencement, who could provide informed consent and were able to complete English questionnaires independently or with assistance. Participants self-reported the presence (1 = none to 5 = very much) of 10 symptoms during each dialysis treatment, the time it took to recover from each treatment, and weekly Kidney Disease Quality of Life 36-Item-Short Form (KDQoL-36) assessments. Principal component analysis identified clusters of intradialytic symptoms. Mixed-effects, ordinal and linear regression examined the association between symptom clusters and recovery time (categorized as 0, >0 to 2, >2 to 6, or >6 hours), and the physical component and mental component scores (PCS and MCS) of the KDQoL-36. One hundred sixteen participants completed 901 intradialytic symptom questionnaires. The most common symptom was lack of energy (56% of treatments). Two intradialytic symptom clusters explained 39% of the total variance of available symptom data. The first cluster included bone or joint pain, muscle cramps, muscle soreness, feeling nervous, and lack of energy. The second cluster included nausea/vomiting, diarrhea and chest pain, and headache. The first cluster (median score: -0.56, 25th to 75th percentile: -1.18 to 0.55) was independently associated with longer recovery time (odds ratio [OR] 1.62 per unit difference in score, 95% confidence interval [CI]: 1.23-2.12) and decreased PCS (-0.72 per unit difference in score, 95% CI: -1.29 to -0.15) and MCS scores (-0.82 per unit difference in score, 95% CI: -1.48 to -0.16), whereas the second cluster was not (OR 1.24, 95% CI: 0.97-1.58; PCS 0.19, 95% CI -0.46 to 0.83; MCS -0.72, 95% CI: -1.50 to 0.06). This was an exploratory analysis of a small data set from 2 centers. Further work is needed to externally validate these findings to confirm intradialytic symptom clusters and the generalizability of our findings. Intradialytic symptoms are correlated. The presence of select intradialytic symptoms may prolong the time it takes for a patient to recover from a dialysis treatment and impair HRQoL.

The role of intra- and interdialytic sodium balance and restriction in dialysis therapies.

The relationship between sodium, blood pressure and extracellular volume could not be more pronounced or complex than in a dialysis patient. We review the patients' sources of sodium exposure in the form of dietary salt intake, medication administration, and the dialysis treatment itself. In addition, the roles dialysis modalities, hemodialysis types, and dialysis fluid sodium concentration have on blood pressure, intradialytic symptoms, and interdialytic weight gain affect patient outcomes are discussed. We review whether sodium restriction (reduced salt intake), alteration in dialysis fluid sodium concentration and the different dialysis types have any impact on blood pressure, intradialytic symptoms, and interdialytic weight gain.

PS-C18-8: MEAN ANNUAL INTRADIALYTIC BLOOD PRESSURE DECLINE AND CARDIOVASCULAR EVENTS IN JAPANESE MAINTENANCE HEMODIALYSIS PATIENTS

Objective: A decline in the intradialytic systolic blood pressure (SBP), which defines intradialytic hypotension, is associated with a greater risk of intradialytic symptoms. Intradialytic SBP decline may be associated with higher all-cause mortality. However, this association has neither been studied in Japanese hemodialysis (HD) patients, nor has seasonal variations in intradialytic SBP decline been considered. We evaluated the association between the mean annual intradialytic SBP decline in Japanese HD patients and clinical outcomes, including major adverse cardiovascular events (MACEs). Design and method: This retrospective cohort study included 47,219 HD sessions in 307 patients undergoing HD over one year (April 2019 to March 2020) in three dialysis clinics. The mean annual intradialytic SBP decline (predialysis SBP-nadir intradialytic SBP) for each patient was determined. The association of the mean annual intradialytic SBP decline with clinical outcomes, including MACEs, was assessed from April 2020 until March 2022. MACEs included cardiovascular death, nonfatal myocardial infarction or unstable angina, stroke, heart failure, and other severe cardiovascular events requiring hospitalization. Results: The study participants included 202 males (66%). The mean patient age was 69.0 ± 12.4 years and the median duration of HD was 4.1 (2.0–7.7) years. The mean annual intradialytic SBP decline was 28.2 ± 14.8 mmHg. MACEs occurred in 77 cases (25%), death or hospitalization due to a decline in Activities of Daily Living (death or hospitalization) occurred in 56 (18%) cases, and all-cause hospitalization occurred in 184 cases (60%). A Cox regression analysis adjusted for age, sex, HD duration, Charlson comorbidity index, and the mean annual predialysis SBP and ultrafiltration rate, showed that a greater intradialytic SBP decline (per 10) was significantly associated with increased risk of MACEs (hazard ratio [HR], 1.30; 95% confidence interval [CI], 1.09–1.54). Moreover, the greater intradialytic SBP decline (per 10) was associated with increased risks of death or hospitalization (HR, 1.32; 95% CI, 1.08–1.62) and all-cause hospitalization (HR, 1.22; 95% CI, 1.07–1.39). Conclusions: In Japanese maintenance HD patients, a greater intradialytic SBP decline was associated with worse clinical outcomes, including increased risks of MACEs, death or hospitalization, and all-cause hospitalization. Further studies are warranted to investigate interventions to attenuate intradialytic SBP decline and improve the prognosis of Japanese HD patients.

Optimization of Dry Weight Assessment in Hemodialysis Patients via Reinforcement Learning.

Dry weight (DW), defined as the lowest tolerated postdialysis weight following the ultrafiltration (UF) of excess fluid volume, is essential for any dialysis prescription for hemodialysis (HD) patients. However, there is no gold standard for DW assessment, and the difficulty of its accurate assessment increases given individual variations and the dynamic changes caused by the uncertainty of patients' condition. Therefore, the current empirical evaluation process is often crude, imprecise, experience-dependent, and energy-consuming. Here, we highlight the personalized dynamic changes in DW over time rather than the more accurate DW assessments at some point in time and formulate the DW evaluation problem into a sequential decision-making process using the Markov decision process (MDP) framework. A reinforcement learning (RL) algorithm based on a dueling double deep Q-network (Duel-DDQN) is proposed to optimize the DW assessment policy, and a multifaceted inspection is applied to assess policy effectiveness and safety. We utilize ten years of data from the Kidney Disease Center, enrolling 750 HD patients and 243,287 dialysis sessions. Good model calibration is confirmed, and off-policy evaluation demonstrates that our policy outperforms other policies, suggesting a decrease of 7.71% in the expected 5-year mortality rate and of 13.44% in the incidence of intradialytic symptoms compared with those of clinicians' strategy. The RL policy adjusts DW more frequently, responds to DW changes more actively, and observes a larger feature space. It is hoped that the proposed solution will help clinicians assess and monitor DW dynamically, making the estimation process more refined, personalized, and intelligent.

Improvement in Quality of Life via Catheter Ablation for Atrial Fibrillation in Patients Undergoing Hemodialysis Therapy

BackgroundAtrial fibrillation (AF) is the most common arrhythmia in patients undergoing hemodialysis (HD); AF lowers quality of life (QoL) and increases the risk of dialysis-related complications. The present study aimed to evaluate the effectiveness of AF ablation on the QoL in patients undergoing HD. MethodsNineteen patients undergoing HD (14 men, age 68 ± 8 years; 15 with paroxysmal AF) who underwent catheter ablation (CA) of AF were enrolled in the study. The Kidney Disease Quality of Life Short Form (KDQOL-SF) was assessed to evaluate the QoL of the HD patients at baseline and 6 months after the ablation. Ablation outcomes and procedural complications were evaluated and compared to those of 1053 consecutive non-HD patients who underwent AF ablation. ResultsThe KDQOL-SF of the HD patients 6 months after the ablation showed an improvement in physical functioning (54 ± 23 to 68 ± 28, P < 0.01), general health perceptions (38 ± 17 to 48 ± 15, P < 0.01), and symptoms/problems (75 ± 21 to 84 ± 13, P = 0.02), compared to baseline. For intradialytic symptoms, dyspnea during HD significantly improved after the CA in the HD patients without AF recurrence (43% to 7%, P = 0.04), whereas the atrial tachyarrhythmias and hypotension during HD remained unchanged. During the follow-up period of 17 ± 13 months after the last procedure, the incidence of being arrhythmia-free was similar (HD patients, 79% vs non-HD patients, 86%, log-rank P = 0.82). No life-threatening complications occurred in any of the patients. ConclusionsCA of AF improves QoL in patients undergoing chronic HD therapy.

MO124: Intradialytic Symptomatology is Largely Patient-Specific in both Haemodialysis and Haemodiafiltration: A Randomized Cross-Over Trial between Four Intermittent Dialysis Modalities

Abstract BACKGROUND AND AIMS Standard haemodialysis is associated with a considerable burden of intradialytic symptoms. Although haemodialysis with cool dialysate is associated with less intradialytic discomfort in general, the incidence of cold sensations increases significantly. Whether treatment with online post-dilution high-volume haemodiafiltration [target convection volume (CV) ≥23 L/session] reduces adverse intradialytic symptoms and provokes cold sensations is unknown. METHOD We performed a randomized controlled cross-over trial in 40 prevalent dialysis patients, who were subjected to two haemodialysis modalities: standard haemodialysis [sHD; dialysate temperature (Td) of 36.5°C] and cool haemodialysis (cHD; Td 35.5°C) and two haemodiafiltration modalities: low-volume haemodiafiltration (lvHDF, CV 15 L/1.73 m2/session, Td 36.5°C) and high-volume haemodiafiltration (hvHDF, CV ≥23 L/1.73 m2/session, Td 36.5°C). Every dialysis modality lasted 2 weeks. Intradialytic symptoms were evaluated after the last session of each dialysis modality, with a slightly modified Dialysis Symptom Index (mDSI). Intradialytic thermal sensations were scored on the Visual Analogue Scale Thermal Perception (VAS-TP) before and after 1 and 3 h of each treatment session. Patients were trained to use the mDSI and VAS-TP, in order to reduce incidental stress and unwanted learning responses due to the trial environment. Repeated measures analysis of variance (ANOVA) and one-way ANOVA were used to measure potential differences in intradialytic symptoms between the dialysis modalities (intraindividual differences) and to assess potential interindividual differences in intradialytic symptoms. Linear mixed models with an interaction term between time and modality were used to determine differences in rate of change of VAS-TP between the four modalities. When appropriate, stratified models were fitted subsequently. RESULTS With the exception of cold sensations during cHD (P = .01), intradialytic symptoms did not differ between modalities, but varied markedly between patients (P &amp;lt; .05 in 11/13 items, Table 1). While the VAS-TP score remained unaltered in sHD, lvHDF and hvHDF, patients felt significantly more cold sensations during cHD (P = .007)(Figure 1). Stratified models showed a decrease of 0.43 points/h on the VAS-TP scale (P = .007) in the first hour of cHD and remained unaltered thereafter [+0.10 points/h (P = .20)]; thermal perception remained unaltered [0.04 points/h (P = .77)] in the other modalities. CONCLUSION Intradialytic symptomatology was, except for the symptom feeling cold, by and large similar in all modalities, but it varied markedly between patients. Hence, adverse intradialytic symptoms seem largely patient-specific. Patients experienced more cold sensations during cool HD, but not during haemodiafiltration.

MO926: Development and Implementation of an Electronic Patient-Reported Outcome System to Support Health-Related Quality of Life Management in a Large, European Dialysis Network

Abstract BACKGROUND AND AIMS Electronic patient-reported outcome measures (ePROMs) may help personalize healthcare for dialysis patients. ePROMs allow patients to self-report their symptoms and disease burden remotely and make the data available to healthcare professionals (HCP) in real-time. Such information can be used for digital phenotyping, symptoms and disease burden monitoring and to enable personalized healthcare through improved outcomes prediction, as well as Screen and Act, N-of-1 trials and treat-to-target approaches. However, routine use of ePROM in clinical practice presents several challenges, including respondent burden and a lack of clear guidance on medical and psycho-educational intervention in response to patients’ complains. We sought to implement a quality improvement programme based on ePROM management in a large network of dialysis patients. METHOD ePROM were collected as part of a screen and act programme launched for the first time in all centres belonging to the Fresenius Medical Care (FMC) Nephrocare network in France (FR), Italy (IT), Spain (SP), UK and Ireland (IR) starting on 20 September 2021. The screening phase ended on 4 December 2021. The action phase is still ongoing. The programme aims at screening all dialysis patients for undetected quality of life and adjustment problems and allow physicians, at their sole discretion, to provide remediation actions potentially including adjustment of treatment plan based on revision of patients’ clinical charts and administration of health education modules. The questionnaire included KDQOL-36, the 5D-Itch questionnaire and an ad hoc module on intradialytic symptoms, and its content was mapped to SONG-HD initiative endpoints. ePROM were collected at the bedside or at patients’ home with a web application available for tablet and smartphones either as self-report or assisted self-report. All ePROM data were recorded in EuCLiD®, the clinical information systems adopted by FMC Nephrocare clinics, as part of patients’ clinical chart. A dashboard displaying patients’ scores was shown to the attending healthcare professional upon survey completion. Statistics about patients’ engagement, scores and action alerts are presented in clinical reports. In the present analysis, we report a retrospective analysis of data abstracted from the EuCliD® database. RESULTS Overall, 152 centres (93%) joined the campaign. Participation statistics across countries are reported in Fig. 1. Among 11 537 active patients treated in the five participating countries, 1553 were ineligible because belonging to non-participating centres, temporarily transferred to other centres outside the network (i.e. vacation, rehabilitation, etc.), hospitalized, or because they were considered unable to respond to the survey (i.e. language barrier, inability to read and write or cognitive impairment). Around 23% (IT) to 30% (FR) were considered eligible with assisted administration only. Attrition rate ranged from 3% (IT) to 15% (FR). Item missingness was &amp;lt;2% for all items throughout the survey except for the item on sexual activity (&amp;gt;10% in all countries). KDQOL-36 scores are reported in Fig. 2; 22.5% reported moderate to very severe pruritus mostly distributed on the head/scalp, chest, abdomen, back, lower legs and thighs, forearm and upper arm (all &amp;gt;30% prevalence). Between 10% (IT) and 20% (UK) reported any complications during their last dialysis session, and between 6% (SP) and 12% (IR) suspended or interrupted treatment because of their symptoms. Prevalence of recovery time &amp;gt;3 h ranged from 34.8% (FR) to 46.4% (IR). CONCLUSION The ePROM quality improvement campaign attained wide participation and low attrition. We found no evidence of respondent burden given the low missingness rate throughout the survey items. The screening phase allowed to collect and organize a wealth of patient-reported outcomes amenable of medical or psycho-educational interventions.

MO1059: A Case Series of 2 Patients with Perdialytic Dialysis Headache: Is There a Role for Isonatremic Dialysis?

Abstract BACKGROUND AND AIMS Per-dialytic headache (PDH) is a frequent complication of hemodialysis (HD) and often a challenge for nephrologists. Its pathophysiology has been though to involve sodium and/or osmotic variation during HD session. We assess here the effect of an Automatic Individualized Sodium Module Management (Na Mngt module) embedded into the dialysis machine on the PHD of two patients. Na Mngt module assesses pre-dialytic plasma sodium concentration and measures it through all the HD duration. Na Mngt module automatically controls the sodium concentration of the dialysate fluid and limits the diffusive sodium load during the HD session. METHOD 2 women aged of 87 and 76 years consistently reported unbearable PDH and nausea during several Online-Hemodiafiltration (HDF) sessions. They did not present other possible causes of PHD, including migraine, nervous depression, disequilibrium syndrome, and arterial hypertension. We suspected that the PDH was favored by dialysis-induced high plasma osmolarity (conductivity) in both patients (conductivity: 135–140 and 138 mmol/L) and decided to put them on Na Mngt module to align the sodium concentration of the dialysate fluid with their predialytic plasma sodium concentration. RESULTS After Na Mngt's activation, The PDH observed in both patients disappeared almost instantly. For both patients ‘1’ and ‘2’, the evolution of the main dialysis parameters before and after Na Mngt activation where respectively: Dry Weight (patient1: 42/41 Kg; patient2: 61/60.5 Kg); Pre-dialysis Sodium (patient1: 131/133 mmol/L; patient2: 143/138 mmol/L); Conductivity (patient1: 135–140/136+/-4 mmol/l; patient2: 140/139 mmol/L); IDWG (patient1: 2.5/2, patient2: 2/1.8 Kg); UF (patient1: 2/1.5 L/session; patient2: 2/1.6 L/session); Diffusive sodium balance (patient1: 10/2 g/session; patient2: 8/0 g/session). The Fig. 1 depicts the evolution of pre- and post-dialysis plasma sodium concentration before and after Na Mngt module activation for patient 1. The Fig. 2 shows for patient 2 the conductivity of the dialysate (in blue) throughout the session compared to the plasma conductivity (in red) with activation of Na Mngt module: the diffusive Na transfer remained around 0 g during ALL the session. For Patient 2, the predialytic plasma Na + was 139 mmol/L, and total Na removed was 18.8 g for the entire session. To obtain these results the dialysis machine module adjusted the dialysate Na within the range of 140–144 mmol/L. CONCLUSION This case report suggests that the Na Mngt module controls the diffusive sodium transfer during HD, reduces sodium load, osmotic fluctuations, and prevents PHD. Na Mngt activation allows isonatremic prescription of sodium with less variation between pre- and post- dialysis plasma sodium concentrations and decreases diffusive Na when isonatremic mode is selected. ‘Patient 2’ shows (Fig. 2) that the Na Mngt tool set a dialysate conductivity slightly higher than Na plasma to obtain an iso-natremic profile. Further controlled clinical study are needed to confirm the effect of the Na Mngt tool on intradialytic (PDH, hypotension) and interdialytic (thirst, IDWG) symptoms.

Evaluation of the relationship between serum carnitine levels and intradialytic complications in children with kidney failure.

Carnitine plays a crucial role in the metabolism of fatty acids as well as energy production. Previous research has suggested a significant decrease in carnitine levels in patients with kidney failure and those undergoing hemodialysis. Therefore, we designed this study to assess the prevalence and characteristics of carnitine deficiency and its association with hemodialysis complications in the pediatric population. This research was a pilot study of 29 children undergoing hemodialysis. Before hemodialysis, a 5-mL blood sample was drawn from each patient through a peripheral vein to measure serum-free carnitine levels, complete blood count with differential, blood urea nitrogen (BUN), creatinine, and electrolytes. Each patient was observed for intradialytic complications, including muscle cramps and hypotension, during 12 sessions of hemodialysis. We included 26 participants with a mean age of 14.23years undergoing hemodialysis. Carnitine deficiency was revealed in 54.8% of our participants. Also, there was no significant correlation between carnitine deficiency and age, gender, and BUN levels (P = 0.698, P = 0.43, and P > 0.05, respectively). Intradialytic complications, including episodes of hypotension and muscle cramps, were more frequent in patients with carnitine deficiency (P = 0.02, P = 0.01, respectively). Other reasons for muscle cramps, such as fluid overload, nutritional status, dialysis regimen, and other important lab results (phosphorus, magnesium, etc.), were ruled out. In conclusion, we found a higher prevalence of carnitine deficiency in pediatric hemodialysis patients. Carnitine deficiency was significantly associated with increased intradialytic symptoms, including muscle spasms and hypotension. Our results could support a potential role of carnitine supplementation in pediatric patients with kidney failure for controlling intradialytic complications, but this requires further investigation. A higher resolution version of the Graphical abstract is available as Supplementary information.

How Would You Prescribe the Dialysate Sodium Concentration for Your Patients?

Low sodium dialysate was commonly used in the early year of hemodialysis to enhance diffusive sodium removal beyond its convective removal by ultrafiltration. However, disequilibrium syndrome was common, particularly when dialysis sessions were reduced to 4 h. The recent trend of lowering the DNa from the most common level of 140 mEq/L has been associated with intradialytic hypotension and increased risk of hospitalization and mortality. Higher DNa also has disadvantages, such as higher blood pressure and greater interdialytic weight gain, likely due to increased thirst. My assessment of the evidence leads me to choose DNa at the 140 level for most patients and to avoid DNa below 138. Patients with intradialytic symptoms may benefit from DNa 142 mEq/L, if they can avoid excessive fluid weight gains.

Soft Target Weight: Theory and Simulation of a Novel Haemodialysis Protocol Which Reduces Excessive Ultrafiltration

Introduction: Excessive ultrafiltration is associated with intra-dialytic symptoms, loss of residual function, and mortality in haemodialysis patients. A major contributor to excessive ultrafiltration is within-individual variation in pre-dialysis weight and the concept of achieving a fixed target weight by the end of each dialysis session. Haemodialysis protocols which allow variable post-dialysis weight have not been proposed. Methods: Weight variation was observed in haemodialysis patients and healthy controls to estimate the proportion of pre-dialysis weight variation which could be considered natural variation. These estimates were used to derive a novel protocol for setting ultrafiltration, which was evaluated by mathematical modelling. Results: Amongst 20 haemodialysis patients, mean (SD) pre-dialysis weight was 102.74 (0.94)% of target weight after a 2-day gap and 103.50 (0.94)% after a 3-day gap. Amongst 10 healthy individuals, mean (SD) daily weight was 100.0 (0.71)% of average weight. A 4-component model of pre-dialysis weight was derived using these estimates, in which the best estimate of pre-dialysis excess fluid is the midpoint of excess weight and average fluid gain, and used to propose a novel protocol for ultrafiltration setting. In simulations, the novel protocol reduced ultrafiltration variation by more than half (standard deviation 0.6 vs. 1.3% of target weight, p < 0.001), without increasing the variation in post-dialysis fluid excess. Excessive ultrafiltration rates (over 13 mL/h/kg) were far less frequent using this protocol (2.6% vs. 7.5% of sessions, p = 0.001). Conclusion: Considering natural weight variation allows the development of a novel protocol for ultrafiltration in which target weight does not have to be achieved precisely: it is therefore a soft target. This protocol, which is predicted to substantially reduce excessive ultrafiltration variation, is a zero-cost intervention with the potential to improve symptoms and clinical outcome for haemodialysis patients.

Real-time prediction of intradialytic relative blood volume: a proof-of-concept for integrated cloud computing infrastructure

BackgroundInadequate refilling from extravascular compartments during hemodialysis can lead to intradialytic symptoms, such as hypotension, nausea, vomiting, and cramping/myalgia. Relative blood volume (RBV) plays an important role in adapting the ultrafiltration rate which in turn has a positive effect on intradialytic symptoms. It has been clinically challenging to identify changes RBV in real time to proactively intervene and reduce potential negative consequences of volume depletion. Leveraging advanced technologies to process large volumes of dialysis and machine data in real time and developing prediction models using machine learning (ML) is critical in identifying these signals.MethodWe conducted a proof-of-concept analysis to retrospectively assess near real-time dialysis treatment data from in-center patients in six clinics using Optical Sensing Device (OSD), during December 2018 to August 2019. The goal of this analysis was to use real-time OSD data to predict if a patient’s relative blood volume (RBV) decreases at a rate of at least − 6.5 % per hour within the next 15 min during a dialysis treatment, based on 10-second windows of data in the previous 15 min. A dashboard application was constructed to demonstrate how reporting structures may be developed to alert clinicians in real time of at-risk cases. Data was derived from three sources: (1) OSDs, (2) hemodialysis machines, and (3) patient electronic health records.ResultsTreatment data from 616 in-center dialysis patients in the six clinics was curated into a big data store and fed into a Machine Learning (ML) model developed and deployed within the cloud. The threshold for classifying observations as positive or negative was set at 0.08. Precision for the model at this threshold was 0.33 and recall was 0.94. The area under the receiver operating curve (AUROC) for the ML model was 0.89 using test data.ConclusionsThe findings from our proof-of concept analysis demonstrate the design of a cloud-based framework that can be used for making real-time predictions of events during dialysis treatments. Making real-time predictions has the potential to assist clinicians at the point of care during hemodialysis.

Dextrose solution for priming and rinsing the extracorporeal circuit in hemodialysis patients: A prospective pilot study.

Introduction:Excess sodium intake and consequent volume overload are major clinical problems in hemodialysis (HD) contributing to adverse outcomes. Saline used for priming and rinsing of the extracorporeal circuit is a potentially underappreciated source of intradialytic sodium gain. We aimed to examine the feasibility and clinical effects of replacing saline as the priming and rinsing fluid by a 5% dextrose solution.Materials and methods:We enrolled non-diabetic and anuric stable HD patients. First, the extracorporeal circuit was primed and rinsed with approximately 200–250 mL of isotonic saline during 4 weeks (Phase 1), subsequently a similar volume of a 5% dextrose solution replaced the saline for another 4 weeks (Phase 2), followed by another 4 weeks of saline (Phase 3). We collected data on interdialytic weight gain (IDWG), pre- and post-dialysis blood pressure, intradialytic symptoms, and thirst.Results:Seventeen chronic HD patients (11 males, age 54.1 ± 18.7 years) completed the study. The average priming and rinsing volumes were 236.7 ± 77.5 and 245.0 ± 91.8 mL respectively. The mean IDWG did not significantly change (2.52 ± 0.88 kg in Phase 1; 2.28 ± 0.70 kg in Phase 2; and 2.51 ± 1.2 kg in Phase 3). No differences in blood pressures, intradialytic symptoms or thirst were observed.Conclusions:Replacing saline by 5% dextrose for priming and rinsing is feasible in stable HD patients and may reduce intradialytic sodium loading. A non-significant trend toward a lower IDWG was observed when 5% dextrose was used. Prospective studies with a larger sample size and longer follow-up are needed to gain further insight into the possible effects of using alternate priming and rinsing solutions lowering intradialytic sodium loading.Trial registration:Identifier NCT01168947 (ClinicalTrials.gov).

Do biochemical parameters and intradialytic symptoms affect post-dialysis recovery time? A prospective, descriptive study.

The recovery time is defined as the time required to recover from the feelings of lassitude and fatigue. The daily activities of patients are affected by dialysis sessions, requiring significant time for patients to return to their routines. This situation implies a lower quality of life for HD patients. The aim of this study was to investigate the effects of biochemical parameters and intradialytic symptoms on post-dialysis recovery time in maintenance HD patients. This study was conducted at a private dialysis center during June and August 2019. Data were collected using the "Descriptive Characteristics Form" and the "Dialysis Symptom Index." "STROBE check-list" was used for the report of the study. The study was completed with 86 participants. The median post-dialysis recovery time was 240 min (interquartile range, 120-360 min), and female patients exhibit significantly higher recovery time than male patients. The median BMI was statistically significantly higher in patients whose post-dialysis recovery time was ≥240 min. Additional findings show that the post-dialysis recovery time was shortened by 0.230 times for male patients, while intradialytic hypotension (IDH) prolonged the median post-dialysis recovery time by 3.141 times. Factors underlying the IDH should be determined in order to eradicate the issue. The study was registered in ClinicalTrials.gov with the number NCT04274556.

Patient-reported symptoms during dialysis: the effect of pre-dialysis extracellular water and change in extracellular water post-dialysis

BackgroundQuality of life for haemodialysis (HD) patients may be affected by symptoms during dialysis treatments, and patient groups have highlighted the need to improve post-dialysis fatigue and dialysis-related symptoms. As changes in extracellular water (ECW) may lead to cramps and other symptoms, we wished to determine whether there was an association between ECW and intra-dialytic symptoms.MethodsWe reviewed the hospital records of HD patients who completed a self-reported intra-dialytic symptom questionnaire, using a visual analogue scale, who had contemporaneous pre- and postdialysis bioimpedance ECW measurements adjusted to height (aECW).ResultsWe studied dialysis sessions of 506 patients, 314 (62.1%) male, 226 (44.7%) diabetic, mean age 64.6 ± 15.7 years, weight 69.9 ± 17.4 kg, and duration of dialysis treatment 26 (9.6–60.1) months. We divided patients into three groups according to pre-dialysis aECW, and total dialysis symptom scores were greater for those in the lower tertile (25 (10–41) vs middle 18 (8.5–34) vs upper 20 (7–31), p < 0.05). Only feeling cold, dizziness, and low blood pressure were statistically different between the three pre-dialysis aECW groups, and there was no difference in post-dialysis recovery times.We analysed the effect of the fall in aECW pre-to post-dialysis. Patients in the group with the greatest fall in aECW did not report more intra-dialytic symptoms or longer recovery times.ConclusionWe found that patients starting dialysis with lower relative ECW were more likely to report intra-dialytic symptoms than those with greater amounts of fluid to remove, and most commonly reported symptoms were associated with intra-vascular volume depletion.

Improvement of the Quality of Life by Catheter Ablation for Atrial Fibrillation in Patients Undergoing Hemodialysis

Introduction: Atrial fibrillation (AF) is the most common arrhythmia in patients undergoing hemodialysis (HD), which lowers the quality of life (QoL) and increases the risk of dialysis related complications. The present study aimed to evaluate the effectiveness of AF ablation on the QoL in patients undergoing HD. Methods: Nineteen patients undergoing HD (14 men, age 68±8years, 15 paroxysmal AF) who underwent catheter ablation (CA) of drug-refractory AF were enrolled in the study (HD group). The Kidney Disease Quality of Life Short Form (KDQOL-SF) was assessed to evaluate the QoL at baseline and six months after the ablation. The ablation outcomes and procedural complications were evaluated and compared to 1053 consecutive patients without HD who underwent AF ablation (non-HD group). Results: During the follow-up period of 17±13 months after the last procedure, the arrhythmia free rate was similar (HD group 79% vs. non-HD group 86% log-rank P=0.82). There were no life-threatening complications in both the two groups. The KDQOL-SF six months after the ablation showed an improvement in the physical functioning (54±23 to 68±28 P<0.01), general health perceptions (38±17 to 48±15 P<0.01) and symptoms/problems (75±21 to 84±13 P=0.02) as compared to the baseline. Regarding the intradialytic symptoms, the dyspnea during HD significantly improved after the CA in the HD patients without AF recurrence (35% to 6% P=0.04), while the atrial tachyarrhythmias and hypotension during HD remained unchanged. Conclusions: CA of AF improves the QoL in patients with chronic hemodialysis.

The effect of chewing gum on dry mouth, interdialytic weight gain, and intradialytic symptoms: A prospective, randomized controlled trial.

The major salivary glands can be stimulated by chewing gum to increase saliva flow and decrease xerostomia. The aim of this study was to investigate the effect of chewing gum on dry mouth, interdialytic weight gain, and intradialytic symptoms in hemodialysis (HD) patients. This prospective randomized controlled single-blind study was conducted with patients who had been treated for at least 6 months with sessions 3 days a week for 4 hours at two HD units. Patients were randomly allocated to chewing gum group or the control group. In the chewing gum group, gum was chewed for 10 minutes six times a day, and when the patients felt mouth dryness or were thirsty. In the nonchewing gum group, gum was not chewed. The patients were followed-up for 3 months. A total of three saliva samples were taken before starting treatment at the first, 12th, and 36th HD session. Data were collected with the "Visual Analogue Scale (VAS)," "Hemodialysis Patients Fluid Control Scale," "Dialysis Symptom Index," and "Hospital Anxiety and Depression Scale" at baseline, week 4, week 8, and week 12. The study was completed with a total of 44 patients consisting of 22 patients in the each group. The second and third month VAS values (xerostomia) of the patients in the chewing gum groups were statistically significantly lower than those in the control group (P = 0.014, P < 0.001, respectively). The third month salivary flow rate in the chewing gum group was higher than the values in the control group patients (P < 0.001). It is anticipated that this study will raise nurses' awareness of dry mouth and encourage future studies on interventions to increase the salivary flow rate to prevent or treat dry mouth.

Effect of ultrafiltration profiling on outcomes among maintenance hemodialysis patients: a pilot randomized crossover trial.

More rapid fluid removal during hemodialysis is associated with adverse cardiovascular outcomes and longer dialysis recovery times. The effect of ultrafiltration (UF) profiling, independent of concomitant sodium profiling, on markers of intradialytic hemodynamics and other outcomes has been inadequately studied. Four-phase, blinded crossover trial. Participants (UF rates > 10mL/h/kg) were assigned in random order to receive hemodialysis with UF profiling (constantly declining UF rate, intervention) vs. hemodialysis with conventional UF (control). Each 3-week 9-treatment period was followed by a 1-week 3-treatment washout period. Participants crossed into each study arm twice (2 phases/arm); 18 treatments per treatment type. The primary outcomes were intradialytic hypotension, pre- to post-dialysis troponin T change, and change from baseline in left ventricular global longitudinal strain. Other outcomes included intradialytic symptoms and blood volume measured-plasma refill (post-dialysis volume status measure), among others. Each participant served as their own control. On average, the 34 randomized patients (mean age 56years, 24% female, mean dialysis vintage 6.3years) had UF rates > 10mL/h/kg in 56% of treatments during the screening period. All but 2 patients completed the 15-week study (prolonged hospitalization, kidney transplant). There was no significant difference in intradialytic hypotension, troponin T change, or left ventricular strain between hemodialysis with UF profiling and conventional UF. With UF profiling, participants had significantly lower odds of light-headedness and plasma refill compared to hemodialysis with conventional UF. Ultrafiltration (UF) profiling did not reduce the odds of treatment-related cardiac stress but did reduce the odds of light-headedness and post-dialysis hypervolemia. Clinicaltrials.gov identifier: NCT03301740 (registered October 4, 2017).