Evidence of Profiled Hemodialysis Efficacy in the Treatment of Intradialytic Hypotension

In the last 10 years the percentage of dialysis patients suffering from clinical intradialytic intolerance has greatly increased. Profiled hemodialysis (PHD) is a new technical approach, alternative to standard hemodialysis (SHD) for the treatment of intradialytic symptomatic hypotension. It is based on intradialytic modulation of the dialysate sodium concentration, using a dialysate sodium concentration profile elaborated by a new mathematical kinetic model. The aim of PHD is to reduce the intradialytic blood volume decrease, thanks to a dialysate sodium profile, which allows a reduction in the plasma osmolarity decrease, thereby boosting intravascular fluid refilling. This work aims at clinically validating the PHD technique, by testing its ability, against SHD, to maintain a more stable intradialytic blood volume; this evaluation was supported by monitoring some hemodynamic parameters. Twelve dialysis patients on SHD treatment were selected because of their intradialytic symptomatic hypotension. Twelve SHD (one per patient) and 12 PHD sessions (one per patient) were performed to achieve the same sodium mass removal and body weight decrease on both PHD and SHD. During these sessions we monitored the blood volume variation % by the critline (a non invasive blood volume monitoring device), the mean blood pressure and heart rate directly and, finally, the stroke volume and cardiac output indirectly by bidimensional doppler-echocardiography. Comparison of the results obtained with the two techniques shows PHD to achieve a significantly more stable blood volume, blood pressure and cardiovascular function than SHD, in particular during the second and the third hour of the dialysis session.

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Implementation of an Algorithm Utilizing Saline Versus Albumin for the Treatment of Intradialytic Hypotension

Annals of Pharmacotherapy ◽

10.1177/1060028018801024 ◽

2018 ◽

Vol 53 (2) ◽

pp. 159-164

Author(s):

Ling Yin ◽

Dennis Dubovetsky ◽

Patricia Louzon-Lynch

Keyword(s):

Blood Pressure ◽

Treatment Failure ◽

Pharmacy Education ◽

Dialysis Session ◽

Intradialytic Hypotension ◽

Dialysis Patients ◽

Total Cost ◽

Treatment Failure Rate ◽

Time Required ◽

Algorithm Implementation

Background: Intradialytic hypotension (IDH) is the most commonly reported complication of hemodialysis (HD) treatment. At our institution, dialysis patients often have both 25% albumin and normal saline ordered as rescue options for management of IDH, without specification of which agent to use first. Objective: The purpose of this study was to determine the effect of an algorithm for IDH management. Methods: A retrospective study was conducted in HD patients who experienced IDH. The primary end point was to evaluate albumin use. Secondary end points included albumin costs, study fluid use per dialysis session, compliance with algorithm, efficacy of hypotension reversal to mean arterial pressure (MAP) ⩾60 mm Hg, percentage of target ultrafiltration achieved, time required to restore systolic blood pressure ⩾90 mm Hg, blood pressure post–study fluids, IDH treatment failure rate, and early termination of dialysis as a result of persistent IDH. Results: Implementation of the algorithm was observed in 94% of patients (n = 90). Total albumin use was significantly reduced from 11 400 to 4700 mL in the pre– (n = 90) and post–algorithm implementation group (n = 90; P < 0.001). The associated total cost of albumin was reduced by 59% ($10 534 vs $4343; P < 0.001). No statistical differences were observed between the 2 groups regarding efficacy of hypotension reversal to MAP ⩾60 mm Hg, early HD termination, or treatment failure rates (all P = 0.99). Conclusion and Relevance: Implementation of an evidence-based, standardized algorithm and pharmacy education to nursing staff can result in a reduction in albumin use and its associated drug costs for IDH management without compromising efficacy of IDH reversal.

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

Kidney and Dialysis ◽

10.3390/kidneydial2010001 ◽

2021 ◽

Vol 2 (1) ◽

pp. 1-3

Author(s):

Friedrich K. Port

Keyword(s):

Blood Pressure ◽

Recent Trend ◽

Sodium Concentration ◽

Intradialytic Hypotension ◽

Sodium Removal ◽

Low Sodium ◽

Interdialytic Weight Gain ◽

Increased Risk ◽

Dialysate Sodium ◽

Intradialytic Symptoms

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.

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Effect of Intravenous Fluids on Blood Pressure Course during Hemodialysis in Hypotensive-Prone Patients

Journal of the American Society of Nephrology ◽

10.1681/asn.v113550 ◽

2000 ◽

Vol 11 (3) ◽

pp. 550-555

Author(s):

FRANK M. VAN DER SANDE ◽

ANTINUS J. LUIK ◽

JEROEN P. KOOMAN ◽

VIC VERSTAPPEN ◽

KAREL M. L. LEUNISSEN

Keyword(s):

Blood Pressure ◽

Hypertonic Saline ◽

Blood Volume ◽

Acute Treatment ◽

Dialysis Session ◽

Intravenous Fluids ◽

Dialysis Patients

Abstract. Hypertonic and hyperoncotic solutions are generally used as acute treatment for symptomatic hypotension during dialysis. Administration of hydroxyethylstarch (HES) was recently shown to be an effective substitution fluid in preserving blood volume (BV) and systolic BP (SBP) in a group of stable dialysis patients during dialysis. In this study, in nine cardiac-compromised dialysis patients with frequent symptomatic hypotensive episodes, the efficacy of three fluids (hypertonic saline [3%], albumin [20%], and HES [10%]) was assessed during three treatment sessions with combined ultrafiltration and hemodialysis, which only differed in the type of fluid administered intravenously. Changes in SBP and relative BV were compared. Fluids were given when SBP was less than 100 mmHg or when the decrease in SBP was more than 25 mmHg versus the start of the treatment. The ultrafiltration was continued at the same rate. When comparing SBP at the end of the dialysis session (t = end) with that at the time of infusion (t = iv), SBP decreased with saline, increased with albumin, and increased significantly with HES. The change in SBP in t = end versus t = iv was significantly greater when using saline compared with HES, and tended to decrease more when using saline compared with albumin (P = 0.09). Between albumin and HES there were no significant differences. BV decreased significantly (t = end) versus baseline (t = 0) during ultrafiltration and hemodialysis in all three treatment sessions. The decrease was significantly higher when using saline compared with albumin and saline compared with HES. Between albumin and HES there were no significant differences. When the values at t = end were compared with those at t = iv, BV decreased, although not significantly, with saline and albumin, but remained unchanged with HES. It is concluded that HES is an effective fluid in maintaining SBP and preserving BV in hypotensive-prone dialysis patients, comparable to albumin but superior to hypertonic saline.

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OCT angiography metrics predict intradialytic hypotension episodes in chronic hemodialysis patients: a pilot, prospective study

Scientific Reports ◽

10.1038/s41598-021-86609-0 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Giuseppe Coppolino ◽

Adriano Carnevali ◽

Valentina Gatti ◽

Caterina Battaglia ◽

Giorgio Randazzo ◽

...

Keyword(s):

Chronic Hemodialysis ◽

Dialysis Session ◽

Intradialytic Hypotension ◽

Inverse Association ◽

Non Invasive ◽

Kaplan Meier ◽

Optimal Thresholds ◽

Scanning Area ◽

Before And After ◽

Capillary Plexus

AbstractIn chronic hemodialysis (HD) patients, intradialytic hypotension (IDH) is a complication that increases mortality risk. We run a pilot study to analyzing possible relationships between optical coherence tomography angiography (OCT-A) metrics and IDH with the aim of evaluating if OCT-A could represent a useful tool to stratify the hypotensive risk in dialysis patients. A total of 35 eyes (35 patients) were analyzed. OCT-A was performed before and after a single dialysis session. We performed OCT-A 3 × 3 mm and 6 × 6 mm scanning area focused on the fovea centralis. Patients were then followed up to 30 days (10 HD sessions) and a total of 73 IDHs were recorded, with 12 patients (60%) experiencing at least one IDH. Different OCT-A parameters were reduced after dialysis: central choroid thickness (CCT), 6 × 6 mm foveal whole vessel density (VD) of superficial capillary plexus (SPC) and 6 × 6 mm foveal VD of deep capillary plexus (DCP). At logistic regression analysis, IDH was positively associated with baseline foveal VD of SCP and DCP, while an inverse association was found with the choroid. In Kaplan–Meier analyses of patients categorized according to the ROC-derived optimal thresholds, CCT, the 3 × 3 foveal VD of SCP, the 3 × 3 mm and 6 × 6 mm foveal VD of DCP and the 6 × 6 mm foveal VD of SCP were strongly associated with a higher risk of IDH over the 30-days follow-up. In HD patients, a single OCT-A measurement may represent a non-invasive, rapid tool to evaluate the compliance of vascular bed to HD stress and to stratify the risk of IDH in the short term.

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Non-Invasive Monitoring of Hemodynamic Parameters during Hemodialysis

The International Journal of Artificial Organs ◽

10.1177/039139889501800904 ◽

1995 ◽

Vol 18 (9) ◽

pp. 499-503 ◽

Cited By ~ 4

Author(s):

F. Pizzarelli ◽

P. Dattolo ◽

M. Piacenti ◽

M.A. Morales ◽

T. Cerrai ◽

...

Keyword(s):

Blood Pressure ◽

Cardiac Output ◽

Blood Volume ◽

Impedance Cardiography ◽

Hemodynamic Parameters ◽

Non Invasive ◽

Transthoracic Impedance ◽

Cardiac Output Index ◽

On Line ◽

Two Parameters

We studied in 13 hemodialysis patients intradialytic variations of blood volume (BV) and cardiac output, by means of non-invasive methods. We found a weak correlation, r 0.2 or less, between BV variations and intradialysis blood pressure variations. The sensitivity of the former in describing the variations of the latter was only 32%. During the 30 min preceeding the hypotensive crisis the percent BV variations did not show any predictive trend. On the contrary, refilling increased as blood pressure dropped and a weak inverse relation (r -0.35) was found between these two parameters. Unstable patients had predialytic blood volume values significantly lower than stable ones and comparable to healthy subjects. On the contrary, the correlation between percent variations of cardiac output index and MAP was 0.68 with a sensitivity and specificity of 90% and 59%, respectively. Unfortunately these promising results were obtained only with an estimate of cardiac output obtained by echocardiography and not by transthoracic impedance cardiography, which is much more feasible than the former as on-line monitoring of cardiac output. On-line monitoring of hemodynamic parameters is an appealing but still unsolved task.

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A Simple Mathematical Model of Intradialytic Sodium Kinetics: “in vivo” Validation During Hemodialysis with Constant or Variable Sodium

The International Journal of Artificial Organs ◽

10.1177/039139889601900704 ◽

1996 ◽

Vol 19 (7) ◽

pp. 393-403 ◽

Cited By ~ 12

Author(s):

M. Ursino ◽

L. Colì ◽

G. La Manna ◽

M. Grilli Cicilioni ◽

V. Dalmastri ◽

...

Keyword(s):

Mathematical Model ◽

Measurement Errors ◽

Sodium Concentration ◽

Mean Deviation ◽

Algebraic Characterization ◽

Dialysis Session ◽

Simple Mathematical Model ◽

Model Predictions ◽

Dialysate Sodium

A simple mathematical model of the intradialytic relationship between natraemia and dialysate sodium concentration is presented. The model includes a bicompartmental description of sodium, urea and fluid kinetics and an algebraic characterization of diffusive/convective mass-transfer across the dialysis membrane. Its ability to provide realistic responses has been validated comparing model predictions by a priori parameter tuning against quantities measured during in vivo sessions with both constant and variable dialysate sodium concentration. A quantitative analysis of model predictions indicates that the mean deviation between data calculated by the model and those measured in vivo is 1.32 mEq/l for sodium and 0.76 mmol/l for urea, values which do not greatly exceed the measurement errors of current instruments. The model's predictive capacity thus proves reliable. The ability of the model to calculate the amount of sodium removed and the time course of intra-extracellular volumes during the dialysis session makes it possible to forecast the patient's clinical tolerance to a given sodium dialysate concentration.

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P1051WHICH MODEL OF DIALYSATE SODIUM PRESCRIPTION TO CHOOSE?

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p1051 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Natasha Eftimovska-Otovikj ◽

Natasha Petkovikj ◽

Elizabeta Poposka ◽

Olivera Stojceva-Taneva

Keyword(s):

Blood Pressure ◽

Serum Sodium ◽

Sodium Concentration ◽

Serum Sodium Concentration ◽

Sodium Balance ◽

Hypertensive Patients ◽

Interdialytic Weight Gain ◽

Sodium Gradient ◽

Set Up ◽

Dialysate Sodium

Abstract Background and Aims The dialysate sodium prescription remain unclear as an important component of sodium balance in HD patients Pre-hemodialysis (pre-HD) serum sodium levels can vary among different patients, therefore, a single dialysate sodium prescription may not be appropriate for all patients. Dialysate sodium is one of the most easy changeable parameter which can influence hemodynamic stability. The aim of the study was to investigate whether dialysis patients will have some beneficial effects of prescription of different models of dialysate sodium Method 77 nondiabetic subjects (41 men; 36 women) performed 12 months hemodialysis (HD) sessions with dialysate sodium concentration set up at 138 mmol/L, followed by additional 3 models of dialysate sodium (each model performed 2 months sessions with 2 months standard dialysate sodium between each model) wherein dialysate sodium was set up: model 1: according to pre-HD serum sodium concentration, model 2: according to sodium concentration in UF fluid, model 3: sodium profiling ( from 144 to 136 mmol/L). Blood pressure (BP), interdialytic weight gain (IDWG), thirst score, sodium gradient were analysed. After the standard dialysate sodium hemodialyses, the subjects were divided into 3 groups: normotensive (N=58), hypertensive (N= 14) and hypotensive (N=5) based on the average pre-HD systolic BP during the standard dialysate sodium hemodialyses. Results Model 1: resulted in significantly lower blood pressure (133,61±11.88 versus 153.60±14.26 mmHg; p=0.000) and IDWG (2.21±0.93 versus 1.87±0.92 kg; p=0.018) in hypertensive patients, whereas normotensive patients showed only significant decrease in IDWG (2.21±0.72 versus 2.06±0.65, p=0,004). Hypertensive patients had significant highest sodium gradient compared to other patients (p<0.05), followed by significant increase of 0,6% IDWG confirmed with univariate regression analysis. Thirst score was significantly lower in all patients with individualized-sodium HD and the use of antihypertensive drugs significantly reduced in hypertensive patients during the individualized phase. Model 2: resulted in significantly lower BP in normotensive and hypertensive patients (126.92±9.71 versus 124.08±8.71 mmHg; p=0.000; 153.60±14.26 versus 138.91±8.48 mmHg, accordingly), with no influence on IDWG, thirst score compared to standard dialysate sodium. Model 3: significantly higher BP and IDWG in all 3 groups (normotensive 126.92±9.71 versus 130.20±9.5 mmHg; p=0.001; IDWG 2.21±0.72 versus 2.34±0.82 kg, p=0,005; hypertensive 153.60±14.26 versus 157.58±5.0 mmHg; IDWG 2.21±0.93 versus 2.39±0.74 kg; p=0.005; hipotensive 79.81±11.78 versus 91.09±24.98 mmHg, IDWG 2.53±0.57 versus 2.73±0.15 kg, p=0.005) and significantly higher thirst score in normotensive and hypotensive patients, with no influence in hypertensive patients. Conclusion A reduction of the dialysate sodium concentration based on the pre HD serum sodium level of the patient, reduced the BP, IDWG, thirst score and use of antihypertensive drug compare to dialysate sodium according to sodium concentration in UF or sodium profiling. We recommend prescription of dialysate sodium according to pre HD serum sodium concentration.

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FP538EFFECTS OF PRESCRIBING DIFFERENT DIALYSATE SODIUM CONCENTRATION ON BLOOD PRESSURE AND LABORATORY PARAMETERS

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfv179.67 ◽

2015 ◽

Vol 30 (suppl_3) ◽

pp. iii252-iii253

Author(s):

Natasa Eftimovska-Otovic ◽

Risto Grozdanovski ◽

Olivera Stojceva-Taneva

Keyword(s):

Blood Pressure ◽

Sodium Concentration ◽

Laboratory Parameters ◽

Dialysate Sodium

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Impaired sympathetic response before intradialytic hypotension: a study based on spectral analysis of heart rate and pressure variability

Clinical Science ◽

10.1042/cs0960023 ◽

1999 ◽

Vol 96 (1) ◽

pp. 23-31 ◽

Cited By ~ 37

Author(s):

Gualtiero PELOSI ◽

Michele EMDIN ◽

Clara CARPEGGIANI ◽

Maria Aurora MORALES ◽

Marcello PIACENTI ◽

...

Keyword(s):

Blood Pressure ◽

Systolic Blood Pressure ◽

Pressure Fluctuations ◽

Power Spectra ◽

Low Frequency ◽

Autonomic Response ◽

Dialysis Session ◽

Intradialytic Hypotension ◽

Sympathetic Response ◽

A Minor

The purpose of this study was to evaluate the autonomic response to standard haemodialysis and the changes associated with the onset of intradialytic hypotension in 12 normotensive patients with uraemia. Power spectra of R–R interval and of blood pressure fluctuations were obtained during a standard dialysis session and estimated in the low-frequency (LF, 30–150 ;mHz) and high-frequency (HF, 150–400 ;mHz) range. The absolute power of the LF component of blood pressure variations and the LF/HF ratio of R–R interval were assumed as indexes of sympathetic activity. Standard haemodialysis induced hypotension in six patients (unstable) while a minor pressure decline was present in the other six (stable). Normalized blood volume before dialysis and percentage volume reduction were similar in the two groups. Tachycardia in response to pressure and volume decrease was more pronounced in stable than in unstable patients, as evidenced by a higher slope of the relation between R–R interval and systolic blood pressure (7.9 versus 0.9 ;ms/mmHg, P< 0.01). Sympathetic tone was enhanced during early dialysis in all patients (+2±1 for R–R LF/HF ratio, +2.4±0.6 ;mmHg2 and +7.2±2 ;mmHg2 for absolute LF power of diastolic and of systolic blood pressure respectively, P< 0.05), compared with baseline predialysis values. During late dialysis, unstable patients showed an impairment of sympathetic activation which preceded hypotension and was maximal during the crisis (-2.9±1.4 for R–R LF/HF ratio, -2.7±1.4 ;mmHg2 and -8.6±4.0 ;mmHg2 for absolute LF power of diastolic and of systolic blood pressure respectively, P< 0.05). On the contrary, stable patients showed constantly elevated indexes (+3.7±1.4 for R–R LF/HF ratio, +5.9±2.7 ;mmHg2 and +13.3±6.2 ;mmHg2 for LF of diastolic and of systolic blood pressure, P< 0.05). Values returned to predialysis levels after the end of the dialysis session in all patients. We conclude that standard haemodialysis activates a marked and reversible sympathetic response in both stable and unstable uraemic patients. However, in unstable patients, such activation is impaired in late dialysis, therefore contributing to the onset of the hypotensive crisis.

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