scholarly journals Hemodynamic response to fluid removal during hemodialysis: categorization of causes of intradialytic hypotension

2018 ◽  
Author(s):  
Nathan W Levin ◽  
Marcia H F G de Abreu ◽  
Lucas E Borges ◽  
Helcio A Tavares Filho ◽  
Rabia Sarwar ◽  
...  
Keyword(s):  
Hemodynamic Response ◽  
Intradialytic Hypotension ◽  
Fluid Removal

Low-Intensity Intradialytic Exercise Attenuates the Relative Blood Volume Drop Due to Intravascular Volume Loss during Hemodiafiltration

2021 ◽  
pp. 1-8
Author(s):  
José Rodríguez-Chagolla ◽  
Raúl Cartas-Rosado ◽  
Claudia Lerma ◽  
Oscar Infante-Vázquez ◽  
Raúl Martínez-Memije ◽  
...  
Keyword(s):  
Aerobic Exercise ◽  
Blood Volume ◽  
Hemodynamic Response ◽  
Intradialytic Hypotension ◽  
Volume Loss ◽  
Vascular Volume ◽  
Acute Response ◽  
Relative Blood Volume ◽  
Intradialytic Exercise ◽  
Cardiovascular Variables

<b><i>Introduction:</i></b> Patients in hemodiafiltration (HDF) eliminate volume overload by ultrafiltration. Vascular volume loss is among the main mechanisms contributing to adverse events such as intradialytic hypotension. Here, we hypothesize that the intradialytic exercise (IDEX) is an intervention that could improve the acute response of physiological mechanisms involved during vascular volume loss. To test this hypothesis, we evaluated the hemodynamic response to mild aerobic exercise during HDF. <b><i>Methods:</i></b> Nineteen end-stage renal disease (ESRD) patients (11 women: 40 ± 10.8 years old, and 8 men: 42 ± 21 years old) receiving HDF thrice a week, with 6 months of previous physical conditioning, participated in this study. Three HDF sessions were scheduled for each patient: 1 resting in supine position, 1 resting in sitting position, and 1 doing aerobic exercise. The first 2 sessions were taken as control. The ultrafiltration rate was set to 800 mL/h in each session. The hemodynamic response was monitored through the relative blood volume (RBV), and cardiovascular variables measured noninvasively by photoplethysmography. Adequacy variables such as Kt/V and percentage reduction of urate, urea, creatinine (Cr), and phosphate were also monitored. <b><i>Findings:</i></b> The decrease rate of the RBV was smaller in the session with IDEX compared to the sessions with no exercise. No differences were found neither in the cardiovascular variables nor in the adequacy variables among the 3 sessions. There were no hypotension events during the session with exercise, and 8 events during the sessions without exercise (<i>p</i> = 0.002). <b><i>Discussion:</i></b> Mild exercise during HDF decreased the RBV drop and was associated with less hypotension events. The lack of differences in the hemodynamic variables suggests an adequate acute response of cardiovascular compensation variables to intradialytic hypovolemia.

scholarly journals Impacts of dialysis adequacy and intradialytic hypotension on changes in dialysis recovery time

2020 ◽  
Vol 21 (1) ◽  
Author(s):  
Murilo Guedes ◽  
Roberto Pecoits-Filho ◽  
Juliana El Ghoz Leme ◽  
Yue Jiao ◽  
Jochen G. Raimann ◽  
...  
Keyword(s):  
Odds Ratio ◽  
Lower Risk ◽  
Recovery Time ◽  
First Year ◽  
Intradialytic Hypotension ◽  
Dialysis Adequacy ◽  
Dialysis Treatment ◽  
Fluid Removal ◽  
Lower Likelihood ◽  
Adjusted Logistic Regression

Abstract Background Dialysis recovery time (DRT) surveys capture the perceived time after HD to return to performing regular activities. Prior studies suggest the majority of HD patients report a DRT > 2 h. However, the profiles of and modifiable dialysis practices associated with changes in DRT relative to the start of dialysis are unknown. We hypothesized hemodialysis (HD) dose and rates of intradialytic hypotension (IDH) would associate with changes in DRT in the first years after initiating dialysis. Methods We analyzed data from adult HD patients who responded to a DRT survey ≤180 days from first date of dialysis (FDD) during 2014 to 2017. DRT survey was administered with annual KDQOL survey. DRT survey asks: “How long does it take you to be able to return to your normal activities after your dialysis treatment?” Answers are: < 0.5, 0.5-to-1, 1-to-2, 2-to-4, or > 4 h. An adjusted logistic regression model computed odds ratio for a change to a longer DRT (increase above DRT > 2 h) in reference to a change to a shorter DRT (decrease below DRT < 2 h, or from DRT > 4 h). Changes in DRT were calculated from incident (≤180 days FDD) to first prevalent (> 365-to- ≤ 545 days FDD) and second prevalent (> 730-to- ≤ 910 days FDD) years. Results Among 98,616 incident HD patients (age 62.6 ± 14.4 years, 57.8% male) who responded to DRT survey, a higher spKt/V in the incident period was associated with 13.5% (OR = 0.865; 95%CI 0.801-to-0.935) lower risk of a change to a longer DRT in the first-prevalent year. A higher number of HD treatments with IDH episodes per month in the incident period was associated with a 0.8% (OR = 1.008; 95%CI 1.001-to-1.015) and 1.6% (OR = 1.016; 95%CI 1.006-to-1.027) higher probability of a change to a longer DRT in the first- and second-prevalent years, respectively. Consistently, an increased in incidence of IDH episodes/months was associated to a change to a longer DRT over time. Conclusions Incident patients who had higher spKt/V and less sessions with IDH episodes had a lower likelihood of changing to a longer DRT in first year of HD. Dose optimization strategies with cardiac stability in fluid removal should be tested.

scholarly journals A randomized trial of albumin infusion to prevent intradialytic hypotension in hospitalized hypoalbuminemic patients

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Etienne Macedo ◽  
Bethany Karl ◽  
Euyhyun Lee ◽  
Ravindra L. Mehta
Keyword(s):  
Sodium Chloride ◽  
Removal Rate ◽  
Vital Signs ◽  
Intermittent Hemodialysis ◽  
Intradialytic Hypotension ◽  
Fluid Removal ◽  
Albumin Infusion ◽  
Disease Outcomes ◽  
Risk Patients ◽  
To Receive

Abstract Background Intradialytic hypotension (IDH) is a frequent complication of intermittent hemodialysis (IHD), occurring from 15 to 50% of ambulatory sessions, and is more frequent among hospitalized patients with hypoalbuminemia. IDH limits adequate fluid removal and increases the risk for vascular access thrombosis, early hemodialysis (HD) termination, and mortality. Albumin infusion before and during therapy has been used for treating IDH with the varying results. We evaluated the efficacy of albumin infusion in preventing IDH during IHD in hypoalbuminemic inpatients. Methods A randomized, crossover trial was performed in 65 AKI or ESKD patients with hypoalbuminemia (albumin < 3 g/dl) who required HD during hospitalization. Patients were randomized to receive 100 ml of either 0.9%sodium chloride or 25% albumin intravenously at the initiation of each dialysis. These two solutions were alternated for up to six sessions. Patients' vital signs and ultrafiltration removal rate were recorded every 15 to 30 min during dialysis. IDH was assessed by different definitions reported in the literature. All symptoms associated with a noted hypotensive event as well as interventions during the dialysis were recorded. Results Sixty-five patients were submitted to 249 sessions; the mean age was 58 ($$\pm$$ ±  12), and 46 (70%) were male with a mean weight of 76 ($$\pm$$ ±  18) kg. The presence of IDH was lower during albumin sessions based on all definitions. The hypotension risk was significantly decreased based on the Kidney Disease Outcomes Quality Initiative definition; (15% with NS vs. 7% with albumin, p = 0.002). The lowest intradialytic SBP was significantly worse in patients who received 0.9% sodium chloride than albumin (NS 83 vs. albumin 90 mmHg, p = 0.035). Overall ultrafiltration rate was significantly higher in the albumin therapies [NS − 8.25 ml/kg/h (− 11.18 5.80) vs. 8.27 ml/kg/h (− 12.22 to 5.53) with albumin, p = 0.011]. Conclusion In hypoalbuminemic patients who need HD, albumin administration before the dialysis results in fewer episodes of hypotension and improves fluid removal. Albumin infusion may be of benefit to improve the safety of HD and achievement of fluid balance in these high-risk patients. ClinicalTrials.gov Identifier: NCT04522635

scholarly journals A Randomized Trial of Albumin Infusion to Prevent Intradialytic Hypotension in Hypoalbuminemic Patients

2020 ◽  
Author(s):  
Etienne Macedo ◽  
Bethany Karl ◽  
Euyhyun Lee ◽  
Ravindra L. Mehta
Keyword(s):  
Sodium Chloride ◽  
Removal Rate ◽  
Vital Signs ◽  
Intermittent Hemodialysis ◽  
Intradialytic Hypotension ◽  
Fluid Removal ◽  
Albumin Infusion ◽  
Risk Patients ◽  
To Receive ◽  
Esrd Patients

Abstract Background: Intradialytic hypotension (IDH) is a frequent complication of intermittent hemodialysis (IHD), occurring from 15 to 50% of ambulatory sessions, and is more frequent among hospitalized patients with hypoalbuminemia 1. IDH limits adequate fluid removal and increases the risk for vascular access thrombosis, early hemodialysis (HD) termination, and mortality. Albumin infusion before and during therapy has been used for treating IDH with varying results. We evaluated the efficacy of albumin infusion in preventing IDH during IHD in hypoalbuminemic inpatients. Methods: A randomized, crossover trial was performed in 65 AKI or ESRD patients with hypoalbuminemia (albumin<3g/dl) who required HD during hospitalization. Patients were randomized to receive 100ml of either 0.9%sodium chloride or 25% albumin intravenously at the initiation of each dialysis. These two solutions were alternated for up to 6 sessions. Patients’ vital signs and ultrafiltration removal rate were recorded every 15 to 30 minutes during dialysis. IDH was assessed by different definitions reported in the literature. All symptoms associated with a noted hypotensive event as well as interventions during the dialysis were recorded. Results: 65 patients were submitted to 249 sessions; mean age was 58 (+/-12), 46 (70%) were male with a mean weight of 76 (+/-18) kg. Presence of IDH was lower during albumin sessions based on all definitions. The risk of hypotension was significantly decreased based on the Kidney Disease Outcomes Quality Initiative (KDOQI) definition; (15% with NS vs. 7% with albumin, p=0.002). Lowest intradialytic SBP was significantly worse in patients that received 0.9% sodium chloride in comparison to albumin (NS 83 vs. Albumin 90 mmHg,p = 0.035). Overall ultrafiltration rate was significantly higher in the albumin therapies (NS -8.25 ml/kg/h (-11.18 -5.80) vs. 8.27ml/kg/h (-12.22 - 5.53) with albumin, p =0.011). Conclusion: In hypoalbuminemic patients who need HD, administration of albumin before dialysis results in fewer episodes of hypotension and improves fluid removal. Albumin infusion may be of benefit to improve safety of HD and achievement of fluid balance in these high-risk patients.ClinicalTrials.gov Identifier: NCT04522635Retrospectively registered in August 21, 2020

scholarly journals Impacts of Dialysis Adequacy and Intradialytic Hypotension on Changes in Dialysis Recovery Time

2020 ◽  
Author(s):  
Murilo Guedes ◽  
Roberto Pecoits-Filho ◽  
Juliana El Ghoz Leme ◽  
Yue Jiao ◽  
Jochen G. Raimann ◽  
...  
Keyword(s):  
Odds Ratio ◽  
Lower Risk ◽  
Recovery Time ◽  
First Year ◽  
Intradialytic Hypotension ◽  
Dialysis Adequacy ◽  
Dialysis Treatment ◽  
Fluid Removal ◽  
Lower Likelihood ◽  
Adjusted Logistic Regression

Abstract Background:Dialysis recovery time (DRT) surveys capture the perceived time after HD to return to performing regular activities. Prior studies suggest the majority of HD patients report a DRT >2hours. However, the profiles of and modifiable dialysis practices associated with changes in DRT relative to the start of dialysis are unknown. We hypothesized hemodialysis (HD) dose and rates of intradialytic hypotension (IDH) would associate with changes in DRT in the first years after initiating dialysis.Methods:We analyzed data from adult HD patients who responded to a DRT survey ≤180 days from first date of dialysis (FDD) during 2014 to 2017. DRT survey was administered with annual KDQOL survey. DRT survey asks: “How long does it take you to be able to return to your normal activities after your dialysis treatment?” Answers are: <0.5, 0.5-to-1, 1-to-2, 2-to-4, or >4 hours. An adjusted logistic regression model computed odds ratio for a change to a longer DRT (increase above DRT >2 hours) in reference to a change to a shorter DRT (decrease below DRT <2 hours, or from DRT >4 hours). Changes in DRT were calculated from incident (≤180 days FDD) to first prevalent (>365-to-≤545 days FDD) and second prevalent (>730-to-≤910 days FDD) years.Results:Among 98616 incident HD patients (age 62.6±14.4 years, 57.8% male) who responded to DRT survey, a higher spKt/V in the incident period was associated with 13.5% (OR=0.865; 95%CI 0.801-to-0.935) lower risk of a change to a longer DRT in the first-prevalent year. A higher number of HD treatments with IDH episodes per month in the incident period was associated with a 0.8% (OR=1.008; 95%CI 1.001-to-1.015) and 1.6% (OR=1.016; 95%CI 1.006-to-1.027) higher probability of a change to a longer DRT in the first- and second-prevalent years, respectively. Consistently, an increased in incidence of IDH episodes/months was associated to a change to a longer DRT over time.Conclusions:Incident patients who had higher spKt/V and less sessions with IDH episodes had a lower likelihood of changing to a longer DRT in first year of HD. Dose optimization strategies with cardiac stability in fluid removal should be tested.

Higher Ultrafiltration Rate Is Associated with Longer Dialysis Recovery Time in Patients Undergoing Conventional Hemodialysis

2017 ◽  
Vol 46 (1) ◽  
pp. 3-10 ◽  
Author(s):  
Wael F. Hussein ◽  
Rohini Arramreddy ◽  
Sumi J. Sun ◽  
Marc Reiterman ◽  
Brigitte Schiller
Keyword(s):  
Recovery Time ◽  
Multivariable Analysis ◽  
Female Gender ◽  
Intradialytic Hypotension ◽  
Ultrafiltration Rate ◽  
Cross Sectional ◽  
Mortality And Morbidity ◽  
Fluid Removal ◽  
Immediate Recovery ◽  
Number Of Patients

Background: Increased mortality and morbidity are reported in association with high ultrafiltration rate (UFR) and with long dialysis recovery time (DRT). We studied the association between UFR and DRT. Methods: This is a cross-sectional, observational study was conducted. Patients on thrice-weekly hemodialysis (HD) with self-reported DRT between August and December 2014 were included. We examined the association of 30-day average UFR with recovery time. Results: The total number of patients included in this study was 2,689. DRT in categories of immediate recovery, >0-≤2, >2-≤6, >6-≤12, and >12 h, were reported in 27, 28, 17, 9, and 20% of the patients respectively. In multivariable analysis, longer DRT was associated with female gender, non-black race, higher body weight, lower serum albumin, chronic heart failure, cerebrovascular disease, missed dialysis sessions, higher pre-dialysis systolic blood pressure, and larger UF volume. Compared to UFR of <10, UFR ≥13 mL/kg/h was associated with longer DRT, OR of 1.16 (95% CI 0.99-1.36), and 1.28 (95% CI 1.06-1.54) in the unadjusted and the adjusted analyses respectively. Intradialytic hypotension was also associated with longer DRT in the unadjusted (per 10% higher frequency, OR 1.04 [95% CI 1.01-1.07]) and adjusted analyses (OR 1.03 [95% CI 1.00-1.07]). Conclusion: Long recovery time is common after HD. Rapid fluid removal is associated with longer DRT.

Intravenous Albumin for Mitigating Hypotension and Augmenting Ultrafiltration during Kidney Replacement Therapy

2020 ◽  
pp. CJN.09670620
Author(s):  
Nicole Hryciw ◽  
Michael Joannidis ◽  
Swapnil Hiremath ◽  
Jeannie Callum ◽  
Edward G. Clark
Keyword(s):  
Current Evidence ◽  
Maintenance Hemodialysis ◽  
Intradialytic Hypotension ◽  
Fluid Removal ◽  
Albumin Administration ◽  
Frequent Use ◽  
Volume Expander ◽  
Kidney Replacement Therapy ◽  
Minimal Data ◽  
Potential Risks

Among its many functions, owing to its oversized effect on colloid oncotic pressure, intravascular albumin helps preserve the effective circulatory volume. Hypoalbuminemia is common in hospitalized patients and is found especially frequently in patients who require KRT either for AKI or as maintenance hemodialysis. In such patients, hypoalbuminemia is strongly associated with morbidity, intradialytic hypotension, and mortality. Intravenous albumin may be administered in an effort to prevent or treat hypotension or to augment fluid removal, but this practice is controversial. Theoretically, intravenous albumin administration might prevent or treat hypotension by promoting plasma refilling in response to ultrafiltration. However, clinical trials have demonstrated that albumin administration is not nearly as effective a volume expander as might be assumed according to its oncotic properties. Although intravenous albumin is generally considered to be safe, it is also very expensive. In addition, there are potential risks to using it to prevent or treat intradialytic hypotension. Some recent studies have suggested that hyperoncotic albumin solutions may precipitate or worsen AKI in patients with sepsis or shock; however, the overall evidence supporting this effect is weak. In this review, we explore the theoretical benefits and risks of using intravenous albumin to mitigate intradialytic hypotension and/or enhance ultrafiltration and summarize the current evidence relating to this practice. This includes studies relevant to its use in patients on maintenance hemodialysis and critically ill patients with AKI who require KRT in the intensive care unit. Despite evidence of its frequent use and high costs, at present, there are minimal data that support the routine use of intravenous albumin during KRT. As such, adequately powered trials to evaluate the efficacy of intravenous albumin in this setting are clearly needed.

scholarly journals Prevention of Intradialytic Hypotension with Intermittent Back-Filtrate Infusion Haemodiafiltration: Insights into the Underlying Mechanism

2019 ◽  
Vol 48 (1) ◽  
pp. 1-6 ◽  
Author(s):  
Yutaka Koda ◽  
Ikuo Aoike
Keyword(s):  
Blood Pressure ◽  
Pilot Study ◽  
Blood Volume ◽  
Physiological State ◽  
Underlying Mechanism ◽  
Intradialytic Hypotension ◽  
Sympathetic Stimulation ◽  
Volume Depletion ◽  
Fluid Removal ◽  
Interdialytic Weight Gain

Background: Intradialytic hypotension (IDH) is a major challenge to safely performing haemodialysis. Blood volume depletion due to fluid removal is a major cause of hypotension, so more emphasis should be placed on finding alternative modalities to traditional constant rate ultrafiltration. Summary: Intermittent back-filtrate infusion haemodiafiltration (I-HDF) utilises purified online quality dialysate with an automated dialysis machine. A bolus of 200 mL of dialysate is repetitively infused at 30-min intervals. A pilot study with 68 hypotension-prone patients revealed that I-HDF can reduce the frequency of IDH interventions, particularly in elderly patients and patients with large interdialytic weight gain (IDWG). This was typically accompanied by an increase in intradialytic blood pressure and decreased tachycardia in the latter half of the session, suggesting reduced sympathetic stimulation during I-HDF. Protective mechanisms involved in the pathophysiology of IDH could be explained in part by the findings obtained in this pilot study. Intermittent increases in blood pressure during I-HDF may prevent venous pooling (i.e., the DeJager-Krogh phenomenon), and reduced sympathetic stimulation may maintain a physiological state less likely to induce the cardio-vagal reflex (i.e., the Bezold-Jarisch reflex). The plasma refilling rate (PRR), evaluated as the refilling fraction (RF), is unexpectedly smaller in I-HDF. However, in patients who respond, the RF is well achieved, which suggests that adequate PRR is the central physiology for preventing IDH. Patients for whom I-HDF is effective are characteristically relatively elderly and show increased IDWG. Blood pressure increment and reduced sympathetic activation in I-HDF may be a mechanism for prevention of IDH. Key Messages: Evaluating relative changes in blood volume during I-HDF will provide a new perspective for exploring appropriate ultrafiltration modification that circumvents IDH.

scholarly journals Impacts of Dialysis Adequacy and Intradialytic Hypotension on Changes in Dialysis Recovery Time

2020 ◽  
Author(s):  
Murilo Guedes ◽  
Roberto Pecoits-Filho ◽  
Juliana El Ghoz Leme ◽  
Yue Jiao ◽  
Jochen G. Raimann ◽  
...  
Keyword(s):  
Lower Risk ◽  
Recovery Time ◽  
First Year ◽  
Intradialytic Hypotension ◽  
Dialysis Adequacy ◽  
Dialysis Treatment ◽  
Fluid Removal ◽  
Patient Reported ◽  
Lower Likelihood ◽  
Adjusted Logistic Regression

Abstract Background: Patient reported long dialysis recovery time (DRT) is common and associated with higher hospitalization and mortality. The goal of our study was to test the hypothesis that hemodialysis (HD) dose and intradialytic hypotension (IDH) rates are associated with dialysis recovery time (DRT). Methods: We analyzed data from adult HD patients who responded to DRT survey ≤180 days from first date of dialysis (FDD) during 2014 to 2017. DRT survey was administered with annual KDQOL survey. DRT survey asks: “How long does it take you to be able to return to your normal activities after your dialysis treatment?” Answers are: <0.5, 0.5-to-1, 1-to-2, 2-to-4, or >4 hours. An adjusted logistic regression model computed odds ratio for increased/maintained longer DRT (increase above DRT >2 hours) in reference to decreased/maintained shorter DRT (decrease below DRT <2 hours, or from DRT >4 hours). Changes in DRT were calculated from incident (≤180 days FDD) to first prevalent (>365-to-≤545 days FDD) and second prevalent (>730-to-≤910 days FDD) years. Results: Among 98616 incident HD patients (age 62.6±14.4 years, 57.8% male) who responded to DRT survey, a higher spKt/V in the incident period was associated with 13.5% (OR=0.865; 95%CI 0.801-to-0.935) lower risk of longer DRT in the first-prevalent year. A higher number of HD treatments with IDH episodes/month in the incident period was associated with a 0.8% (OR=1.008; 95%CI 1.001-to-1.015) and 1.6% (OR=1.016; 95%CI 1.006-to-1.027) higher probability of a longer DRT in the first- and second-prevalent years, respectively. Consistently, an increased in incidence of IDH episodes/months was associated to longer DRT over time. Conclusions: Incident patients who had higher spKt/V and less sessions with IDH episodes had a lower likelihood of longer DRT in first year of HD. Dose optimization strategies with cardiac stability in fluid removal should be tested.

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