Postdialysis Mean Arterial Pressure Research Articles

CONTRIBUTING FACTORS OF INTRADIALYTIC HYPERTENSION IN MAINTENANCE HAEMODIALYSIS PATIENTS

Objective: The objective of this study was to determine the proportion of IDH and to evaluate its association with fluid overload using Bioimpedance Analysis (BIA). Design and method: A cross-sectional study involving 130 chronic haemodialysis patients in Cipto Mangunkusumo hospital Jakarta. This study is conducted between September to November 2019. IDH was defined as an increase in Mean Arterial Pressure (MAP) of at least 15 mmHg within or after dialysis or an increase of systolic blood pressure more than 10 mmHg after dialysis. Results: The prevalence of IDH was 17,7% (n = 23). There was a trend towards predialysis excess fluid in the IDH group with 10 (45,5%) samples when compared with NIDH with 35 (32,7%) samples respectively; as measured by BCM (p = 0.184). A trend towards use of more than 3 antihypertensives was noted in the IDH group [12 (52,1%) samples versus <3 types was 11 (47.8%) samples; p > 0.000]. On bivariate analysis, post dialysis blood pressure and post dialysis MAP are significantly greater in IDH group, as expected. None of the predialysis blood pressure, BMI, ultrafiltration, and serum sodium were associated with incident of IDH Conclusions: The prevalence of IDH in our treatment centres is 17,7%. Subclinical fluid overload was found higher in IDH patients, although statistically non significant. The use of BIA identifies patients who may benefit from additional UF.

VP149 Sustained Low Efficiency Dialysis (SLED): A Rapid Review

INTRODUCTION:This rapid review aimed to determine the effectiveness of Sustained Low Efficiency Dialysis (SLED) when compared to Continuous Renal Replacement Therapy (CRRT) and Continuous Veno-Venous Hemofiltration (CVVH) in the treatment of acute renal failure (ARF) with a view to implementing SLED in a tertiary hospital in 2014.METHODS:A rapid review was performed on the effect of SLED for patients with ARF compared with CRRT or CVVH. The outcomes of interest were mortality, hemodynamic stability, reduced utilization of intensive care unit (ICU) and cost-effectiveness. The search terms ("sustained low-efficiency dialysis[MESH]”) were used to search PubMed, the Cochrane Library, UK NHS Centre for Reviews and Dissemination databases and the US National Guidelines Clearinghouse for relevant articles until 2014.RESULTS:Four observational and two randomized controlled trial (RCT) studies were found. The results showed that 90-day mortality, was similar between groups (SLED: 49.6 percent versus CVVH: 55.6 percent, p = .43). Hemodynamic stability did not differ between SLED and CVVH and between SLED and CRRT. Patients in the SLED group had significantly fewer days of mechanical ventilation (17.7 ± 19.4 versus 20.9 ± 19.8, p = .047) and fewer days in the ICU (19.6 ± 20.1 versus 23.7 ± 21.9, p = .04). Patients treated with SLED needed fewer blood transfusions (1,375 ± 2,573 ml versus 1,976 ± 3,316 ml, p = .02) and had a substantial reduction in nursing time (p < .001). The hospital weekly costs were CAD1,431 for SLED, CAD2,607 for CRRT with heparin, and CAD 3,089 for CRRT with citrate. Dialysis using SLED was associated with higher first post-dialysis mean arterial pressure (p = .003) than those treated with CVVH, which led to lower mortality.CONCLUSIONS:The evidence suggests that SLED can be used as an alternative to CRRT, as the outcomes were similar. SLED provides solute removal equivalent to CRRT at significantly lower cost.

Association of Serum Albumin and Duration of Dialysis with Blood Pressure in Hemodialysis Unit at Academic Hospital Gadjah Mada University Yogyakarta

Background: Hypertension is very common in dialysis patients. The pathogenesis of hypertension is multifactorial and is not completely understood. Objective: To study association between age, dialysis adequacy index (Kt/V), duration of dialysis, serum albumin, uric acid, ultrafiltration volume, parathyroid hormone, hemoglobin, hematocrit, calcium, phosphorus, calcium-phosphorus (ca x ph) product and blood pressure in dialysis patients. Method: Fifty hemodialysis patients were included in a cross-sectional study in a dialysis unit during a 3-months period. Data were analyzed using linear regression analysis. Result: Fifty hemodialysis patients were included in a cross-sectional study in a dialysis unit during a 3 months period, start from October until December 2014. Albumin was significantly associated with predialysis systolic blood pressure (P = .05, R = −0,302). Duration of dialysis was significantly associated with predialysis systolic blood pressure (P = .00, R = −0.594), predialysis diastolic blood pressure (P = .045, R = −0.285), predialysis mean arterial pressure (P = .00, R = −0.502), and postdialysis mean arterial pressure (P = .018, R = −0.334). There is no association between blood pressure and age, dialysis adequacy index (Kt/V), uric acid, ultrafiltration volume, parathyroid hormone, hemoglobin, hematocrit, calcium, phosphorus, ca x ph product were detected. Conclution: The study findings suggest that serum albumin is significantly associated with predialysis systolic blood pressure and duration of dialysis is significantly associated with predialysis systolic blood pressure, predialysis diastolic blood pressure, predialysis mean arterial pressure, and postdialysis mean arterial pressure.

Blood Pressure and Cardiovascular Mortality in Dialysis Patients With Left Ventricular Systolic Dysfunction

In patients chronically treated with hemodialysis, the prevalence of heart failure is high with a consequently poor prognosis. The role played by blood pressure (BP) on cardiovascular (CV) mortality of these patients has not been clearly defined. In this follow-up study, we investigated the relationship of pre- and postdialysis measurements of BP with CV and all-cause mortality in a cohort of 557 dialysis patients with a left ventricular (LV) ejection fraction <50%. During the follow-up (mean = 21.6 ± 8.8 months), 179 deaths were recorded. Ninety-eight patients died from CV causes. By the Cox multivariable analysis, we constructed a predictive model of CV mortality including age, duration on dialysis, diabetes, serum albumin, diffusive dialysis technique, predialysis mean arterial pressure (MAP) (hazard ratio (HR) = 0.978; 95% confidence interval (CI) = 0.956-0.999), and postdialysis MAP (HR = 1.035; 95% CI = 1.010-1.061). The relationship with mortality was inverse for predialysis MAP and direct for postdialysis MAP. In a subsequent analysis, we found that pre- and postdialysis systolic BP, but not diastolic BP, were predictive of CV mortality. Predialysis MAP was in a direct relationship with body mass index. Postdialysis MAP had an inverse relationship with weight loss during dialysis session. CV mortality in dialysis patients with LV dysfunction is associated with both pre- and postdialysis BP interacting in a complex relationship. Nutritional state and fluid balance and removal are possible clues to this relationship.

Does a reduction in dialysate sodium improve blood pressure control in haemodialysis patients?

There has been debate as to the value of lower sodium dialysates to control blood pressure in haemodialysis patients, as sodium is predominantly removed by ultrafiltration. Re-audit of clinical practice following reduction in dialysate sodium concentration. Overall dialysate sodium concentration decreased from 138.9 ± 1.7 to 137.8 ± 1.7 mmol/L (mean ± standard deviation), resulting in a reduction in pre- and post-dialysis mean arterial pressure (MAP) of 4 mmHg (from 100.6 ± 15.6 to 97.1 ± 15.6, P < 0.01 and from 91.7 ± 15.6 to 87.1 ± 14.6, P < 0.001 respectively), yet fewer patients were prescribed antihypertensives (49.6 vs 60.6%), and less antihypertensive medications/patient (mean 0.86 vs 1.05), ultrafiltration requirements (2.8% vs 3.2% body weight, P < 0.001), and symptomatic intradialytic hypotension (0.19 vs 0.28 episodes per week, P < 0.001). A multivariable model showed that for a dialysate sodium of 136 mmol/L, younger patients had higher MAP than older patients (0.35 mmHg lower MAP/year older; but with a dialysate sodium of 140 mmol/L, there was minimal association of MAP with age (0.07 mmHg higher MAP/year older). Change in clinical practice, amounting to a modest reduction in dialysate sodium was associated with a reduction not only in pre- and post-dialysis blood pressures, but also ultrafiltration requirements and symptomatic intradialytic hypotension. However, this effect on blood pressure was most marked for older patients and women, within minimal effects for younger patients, and lesser effects for men, suggesting that dialysate sodium reduction alone may help improve blood pressure control, but requires additional factors such as dietary sodium restriction to be effective in younger male patients.

Association of calcium-phosphorus product with blood pressure in dialysis.

Hypertension is very common in dialysis patients. Disorders of mineral metabolism have been linked to vascular calcification and hypertension in dialysis. Fifty-four hemodialysis patients were included in a cross-sectional study in a dialysis unit during a 6-month period. Linear regression analysis was done between averages of calcium and phosphorus (ca x ph) product and blood pressures (BPs). Ca x ph was significantly associated with systolic BP predialysis (P=.03, R=0.28), diastolic BP predialysis (P=.001, R=0.44), predialysis mean arterial pressure (MAP) (P=.002, R=0.4), and diastolic BP postdialysis (P=.03, R=0.26). No relationship was found with pulse pressures. Multilinear regression analysis was then done between ca x ph product and BPs adjusting for age, sex, hemoglobin, diabetes, albumin, parathyroid hormone, ultrafiltration volume, and average BP medications per patient. There was a strong positive association with predialysis systolic BP (P=.003, R(2)=0.49), predialysis MAP (P=.001, R(2)=0.51), and postdialysis MAP (P=.02, R(2)=0.65). No associations with pulse pressures were detected. The study findings suggest that ca x ph product is significantly associated with dialysis MAP and not pulse pressure. This is likely secondary to the stronger relationship with diastolic BP than with systolic BP. Prospective studies looking into the associated hemodynamic parameters related to arterial stiffness and endothelial dysfunction along with measures for calcifications would be very beneficial.

Sustained low-efficiency dialysis versus continuous veno-venous hemofiltration for postsurgical acute renal failure

Background In postsurgical acute renal failure patients with moderate unstable hemodynamics or fluid overload, the choice of dialysis modality is difficult. This study was performed to compare the outcomes between the sustained low-efficiency dialysis (SLED) and continuous veno-venous hemofiltration (CVVH) in these patients. Methods Sequential postsurgical acute renal failure patients undergoing acute dialysis with CVVH (2002–2003), or SLED (2004–2005) as a result of severe fluid overload or moderately unstable hemodynamics were analyzed. Multivariate analyses of comorbidity, disease severity before initiating dialysis, biochemical measurements, and hemodynamic parameters for 3 days after the first dialysis session were performed by fitting multiple logistic regression models to predict patient's 30-day after hospital discharge (AHD) mortality. Results Among the 101 recruited patients, 38 received SLED and the rest received CVVH. The 30-day AHD mortality was 62.4%. The independent risk factors of 30-day AHD mortality included older age ( P = .008), lower first postdialysis mean arterial pressure (MAP) ( P = .021), higher first postdialysis blood urea nitrogen level ( P = .009), and absence of a history of hypertension ( P = .002). A further linear regression analysis found that dialysis using SLED was associated with higher first postdialysis MAP ( P = .003). Conclusions Among the postsurgical patients requiring acute dialysis with severe fluid overload or moderately unstable hemodynamics, the patients treated with SLED had a higher first postdialysis MAP than those treated with CVVH, which led to lower mortality. Further multicenter randomized clinical trials of larger sample size are needed to compare the effects of SLED and CVVH on the outcomes of postsurgical acute dialysis patients.

A systematic review of the clinical effects of reducing dialysate fluid temperature

Intradialytic hypotension (IDH) is a frequent complication of haemodialysis. Reducing the temperature of the dialysis fluid is a simple therapeutic strategy but is relatively underused. This may be due to concerns regarding its effects on symptoms and dialysis adequacy. We performed a systematic review of the literature to examine the effects of cool dialysis on intradialytic blood pressure, and to assess its safety in terms of thermal symptoms and small solute clearance. We searched the Cochrane Central Register of Controlled Trials, Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, databases of ongoing trials, the contents of four major renal journals as well as hand-searching reference lists. We included all prospective randomized studies that compared any technique of reducing dialysate temperature with standard bicarbonate dialysis. These techniques included an empirical, fixed reduction of dialysate temperature or use of a biofeedback temperature-control device (BTM) to deliver isothermic dialysis or programmed patient cooling. A total of 22 studies comprising 408 patients were included (16 studies examined a fixed empirical temperature reduction and six examined BTM). All studies were of crossover design and relatively short duration. IDH occurred 7.1 (95% CI, 5.3-8.9) times less frequently with cool dialysis (both fixed reduction and BTM). Post-dialysis mean arterial pressure was higher with cool-temperature dialysis by 11.3 mmHg (95% CI, 7.7-15.0). No studies reported that cool dialysis led to a reduction in dialysis adequacy as assessed by urea clearance. The frequency and severity of thermal-related symptoms were generally reported inadequately. Reducing the temperature of the dialysate is an effective intervention to reduce the frequency of IDH and does not adversely affect dialysis adequacy. This applies to the fixed reduction of dialysate temperature and BTM. It remains unclear as to what extent cool-temperature dialysis causes intolerable cold symptoms during dialysis. There are no trials comparing fixed empirical temperature reduction with BTM, and no trials examining the long-term effects of cool dialysis on patient outcomes.

Nocturnal Hemodialysis Is Better Than Quotidian Hemodialysis

Background. It is unknown whether long nocturnal (6–7 times weekly 6–8 hours) hemodialysis (NHD) is better than frequent short hemodialysis (‘daily’, quotidian hemodialysis, QHD). Methods. A Dutch NHD pilot study (‘Nocturne’) started in December 2001. We can now evaluate effects of 4 months NHD in 14 patients. Baseline dialysis frequency was 3.5 or less (3.13 ± 0.23, M ± SD) in group A (n = 8), and 4 or more (5.0 ± 0.89) in group B (n = 6), weekly dialysis time was equal in both groups. Results. Single pool Kt/V, being higher in group B at baseline, increased in both groups (A: 3.1 ± 0.8/week to 9.5 ± 2.3, B: 3.8 ± 1.0 to 10.9 ± 4.1). Baseline nPCR, being higher in group B, increased in both groups (A: 1.0 ± 0.3 g/kg/week to 1.4 ± 0.3, and B: 1.2 ± 0.5 to 1.8 ± 0.5). Baseline albumin was higher in group B, and increased in group A (39.6 ± 3.7 g/l to 43.2 ± 1.5), not in B (41.4 ± 2.3 to 42.8 ± 2.3). Target weight increased only in group A (71.8 ± 10.5 kg to 75.3 ± 11.9), not in B (71.4 ± 25.5 to 71.3 ± 26.7). NHD resulted in normophosphatemia in both groups despite phosphate supplementation and cessation of phosphate binders. PTH decreased in both groups (A: 40.6 ± 38.0 pmol/l to 14.4 ± 11.7, B: 35.6 ± 37.7 to 22.4 ± 41.5). In both groups, pre- and postdialysis mean arterial pressure decreased (A: 106.8 ± 7.9 mmHg to 94.4 ± 12.1 and 97.3 ± 9.5 mmHg to 86.3 ± 8.2, B: 102.2 ± 28.4 to 89.4 ± 9.5 and 90.3 ± 26.8 to 82.7 ± 12.9). Antihypertensives were discontinued or markedly reduced. Fatigue, insomnia, prurigo, restlessness, appetite, physical condition, working ability and quality of life (SF36) improved significantly in both groups. Conclusion. This small pilot study suggests that phosphate and PTH control, blood pressure, uremic symptoms and quality of life improve when conventional hemodialysis or QHD patients switch to NHD. Nutritional parameters improve only in the previously conventionally treated group.

Ultrafiltration Volume Is Associated with Changes in Blood Pressure in Chronically Hemodialyzed Patients

Introduction. Volume overload is a main factor in development of hypertension in hemodialysis patients. In order to demonstrate impact of ultrafiltration volume on blood pressure during 15-months period in a group of patients undergoing chronic hemodialysis therapy, we conducted this study. We hypothesized that ultrafiltration volume different affects the pre/postdialysis systolic pressure, diastolic pressure, mean arterial pressure (MAP), and pulse pressure (PP) values. Subjects and Methods. Study subjects were 23 anuric chronically hemodialyzed patients. The overall study time was 15 months, and 136 single hemodialysis treatments were analyzed. Results. Ultrafiltration was negatively correlated with predialysis systolic blood pressure (r = −0.169, p = 0.025), postdialysis systolic blood pressure (r = −0.292, p<0.001), postdialysis MAP (r = −0.186, p = 0.015), predialysis PP (r = −0.290, p<0.001), and postdialysis PP (r = −0.370, p<0.001). Ultrafiltration/dry body mass (UF/W) ratio was negatively correlated with predialysis PP (r = −0.222, p = 0.005), postdialysis PP (r = −0.340, p<0.001), and postdialysis systolic blood pressure (r = −0.243, p = 0.002). We found significant difference in postdialysis PP between dialyses with UF/W ratio ≤0.05 and dialyses with UF/W ratio >0.05 (63.49 ± 20.76 vs. 56.27 ± 16.33 mmHg, p = 0.033). Conclusion. The ultrafiltration volume strongly affects postdialysis PP values. Evaluation of elevated blood pressure treatment in patients undergoing chronic hemodialysis therapy must be considered in respect of postdialysis PP values, not just depending on pre/postdialysis systolic and diastolic pressure or MAP values.

Effect of dialysate composition on intercompartmental fluid shift

Effect of dialysate composition on intercompartmental fluid shift and hemodynamics was studied in 12 patients during 1.5 or 2 hours of hemodialysis without net ultrafiltration, using high (H;Na 154 mmol/liter), normal (N;Na 140 mmol/liter) or low (L:Na 126 mmol/liter) concentration dialysate. H dialysate was associated with a small (0.9%) increase in blood volume, a larger increase in plasma volume and a decrease in erythrocyte volume. L dialysate resulted in a 2.3% decrease in blood volume, a larger decrease in plasma volume and an increase in erythrocyte volume. N dialysate gave results which were intermediately between the other two dialysis conditions. There was no difference in the post-dialysis mean arterial pressure between the groups, although heart rate increased more during H dialysis than during the other two conditions. Change in blood and erythrocyte volume correlated significantly with change in plasma Na concentration and osmolality, but not with change in plasma urea concentration. We conclude that dialysate composition affects the movement of water into and out of the plasma and erythrocytes in a manner that can be accounted for by altered plasma concentrations of osmotically active substances.