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 SSRI use in pregnancy: Evaluating the risks and benefits

2015 ◽  
Vol 21 (2) ◽  
pp. 6
Author(s):  
Elsa Du Toit ◽  
Eileen Thomas ◽  
Liezl Koen ◽  
Bavi Vythilingum ◽  
Stoffel Grobler ◽  
...  
Keyword(s):  
Antidepressant Treatment ◽  
Severe Depression ◽  
Evidence Base ◽  
Current Evidence ◽  
Benefit Analysis ◽  
Medication Effects ◽  
Current Evidence Base ◽  
Pregnancy And Lactation ◽  
Potential Risks ◽  
Risk Benefit Analysis

<p>Selective serotonin reuptake inhibitor (SSRI) antidepressants are considered the primary pharmacological treatment for moderate to severe depression during pregnancy.<span><em> </em></span>Data regarding the safety of their use during pregnancy remain controversial and conflicting. Decisions regarding the prescription of antidepressant treatment are often fraught with concern around potential harmful medication effects on the pregnancy, fetus and infant. Information on potential risks remains extremely varied and inconsistent across sources. This lack of clarity regarding drug safety brings significant uncertainty not only for treating physicians, but also for women seeking information about depression during pregnancy. This review aims to summarise and evaluate the current evidence base and to aid clinicians in performing a risk/benefit analysis for SSRI use during pregnancy and lactation.</p><div> </div>

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.

P1477EFFECT OF INTRADIALYTIC EXERCISE IN A MEXICAN MAINTENANCE HEMODIALYSIS POPULATION

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Carlos Chavez-Mendoza ◽  
LUIS IGNACIO MANZO-ARELLANO ◽  
AIRY SANTILLÁN-CERÓN ◽  
SAGRARIO CASTILLO-JUÁREZ ◽  
CÉSAR ULISES RAMÍREZ-SALGADO ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Total Population ◽  
Exercise Program ◽  
Maintenance Hemodialysis ◽  
Intradialytic Hypotension ◽  
Bone Mineral Status ◽  
History Of ◽  
The Mean ◽  
Intradialytic Exercise

Abstract Background and Aims The use of intradialytic exercise has been associated with improved clearance, oxygen consumption, quality of life, and physical performance. The aim of this study was to describe the association between of intradialytic exercise and some outcomes in a Mexican maintenance hemodialysis (HD) population. Method Observational comparative study that included 84 maintenance HD patients from one HD center in Mexico City. The population was grouped according to the intradialytic exercise local record. The aerobic intradialytic exercise protocol includes cycling for 30-45 min during the first 2 hours of the HD according to each patient’s ability. A retrospective registry of clinical and biochemical parameters was realized. Also, the hemodynamic parameters of the last six HD sessions for each patient was included. Data analysis was carried out through descriptive and inferential statistics. Results Of the total population, 45.2% were men (n= 38) and the mean age was 53.6 + 17 years. Fifty one percent (n= 43) had diabetes mellitus (DM), which resulted more prevalent in the subgroup of patients without intradialytic exercise (p=0.03) No differences between groups were present in age, history of previous peritoneal dialysis or kidney transplant. The rest of baseline data are shown in Table 1. The subgroup of patients who underwent intradialytic exercise presented higher levels of serum albumin (p=0.03) and lower levels of parathormone (p=0.03). A total of 504 HD sessions were analysed and intradialytic exercise was performed in 64.3% (n=324). Patients in the intradialytic exercise program presented high levels of systolic and diastolic blood pressure (graphic 1). Intradialytic hypotension occurred in 5.2% (n=26) and no differences are shown between groups (p=0.78). No mayor side effects were reported. Conclusion The intradialytic exercise could improve nutritional and bone-mineral status markers. The patients in an intradialytic exercise program presented higher levels of blood pressure.

scholarly journals Hemodynamic Response to Glucose-Insulin Infusion and Meals during Hemodialysis

2020 ◽  
Vol 45 (2) ◽  
pp. 249-262 ◽  
Author(s):  
Christoffer Svinth-Johansen ◽  
Mark Reinhard ◽  
Per Ivarsen
Keyword(s):  
Insulin Infusion ◽  
Pulse Wave ◽  
Augmentation Index ◽  
Hemodynamic Instability ◽  
Maintenance Hemodialysis ◽  
Intradialytic Hypotension ◽  
Hemodynamic Parameters ◽  
Wave Analysis ◽  
Meal Intake ◽  
Meal Study

Introduction: Intradialytic nutrition may improve nutritional status and reduce mortality in patients on maintenance hemodialysis (HD) but has been associated with adverse events, mainly hemodynamic instability. Some dialysis centers therefore restrict intradialytic meals. In 2 clinical studies, we investigated the effects of intradialytic glucose-insulin infusion (GII) and meal intake on blood pressure (BP), pulse wave velocity (PWV), pulse wave analysis (PWA), and cardiac output (CO). PWA yielded augmentation index standardized with heart rate 75 (AIx@HR75). Methods: In the GII study, 12 nondiabetic HD patients had BP, PWV, PWA, and CO measured during 3 HD sessions: standard HD, HD with glucose infusion, and HD with GII. In the Meal study, 12 nondiabetic patients had BP and PWA measured on 3 study days: meal alone (non-HD), meal and HD, 2 meals and HD. Twelve matched healthy controls completed the non-HD day. Findings: In the GII study, glucose or GII had no additional effects on hemodynamic parameters compared with standard HD. HD resulted in a decrease in systolic BP of 13%, in diastolic BP of 9%, in AIx@HR75 of 17%, and CO of 18%. PWV was reduced by only 5%. In the Meal study, a meal alone did not change BP, whereas the combined influence of HD and meal intake reduced systolic BP with 22% and diastolic BP with 19%. Furthermore, AIx@HR75 decreased by 37% on HD days and by 36% in controls, but was unaffected on non-HD days. Discussion: In the GII study, HD significantly reduced BP, AIx@75, and CO, whereas PWV remained almost constant. No additional effects were observed by concomitant GII during HD. BP reductions seemed larger in the Meal study compared with the GII study. Taken together, HD per se appears as the main discriminant for intradialytic hypotension but in hemodynamically unstable patients the timing and route of nutrition provision should be considered carefully.

‘It depends on the consultation’: revisiting use of family members as interpreters for general practice consultations – when and why?

2017 ◽  
Vol 23 (3) ◽  
pp. 257 ◽  
Author(s):  
Jo Hilder ◽  
Ben Gray ◽  
Anthony Dowell ◽  
Lindsay Macdonald ◽  
Rachel Tester ◽  
...  
Keyword(s):  
Family Member ◽  
Best Practice ◽  
Good Practice ◽  
Family Members ◽  
Patient Comfort ◽  
Cultural Norms ◽  
Communication Analysis ◽  
Frequent Use ◽  
Medical Consultations ◽  
Potential Risks

Family members continue to be used as interpreters in medical consultations despite the well-known risks. This paper examines participant perceptions of this practice in three New Zealand clinics chosen for their frequent use of interpreters and their skill in using them. It is based on a detailed study of 17 video-recorded interpreted consultations and 48 post-consultation interviews with participants (5 doctors, 16 patients and 12 interpreters, including 6 family members). All participants expressed satisfaction with the communication. Analysis of the interviews explored what participants liked or valued about family member interpreters (FMIs). Key themes were the FMIs’ personal relationship and knowledge, patient comfort, trust, cultural norms, time efficiency and continued help outside the consultation. General practitioners (GPs) expressed awareness of potential risks and how to manage them, in contrast to patients and FMIs. Although the use of professional interpreters needs to be strongly promoted, a well-informed decision to use a family member is appropriate in some situations. GPs need to be well trained in how to assess and manage the risks. Rather than striving for ‘best practice’ (i.e. universal use of professional interpreters), it is better to aim for ‘good practice’ where a considered judgement is made about each situation on an individual basis.

scholarly journals Canadian Urological Association position statement on the use of transvaginal mesh

2017 ◽  
Vol 11 (6S2) ◽  
pp. 105 ◽  
Author(s):  
Blayne Welk ◽  
Kevin V. Carlson ◽  
Richard J. Baverstock ◽  
Stephen S. Steele ◽  
Gregory G. Bailly ◽  
...  
Keyword(s):  
Pelvic Organ Prolapse ◽  
Pelvic Floor ◽  
Stress Incontinence ◽  
Position Statement ◽  
Pelvic Organ ◽  
Transvaginal Mesh ◽  
Current Evidence ◽  
Prolapse Repair ◽  
Potential Risks ◽  
High Level

Stress incontinence (SUI) and pelvic organ prolapse (POP) are common conditions. There is high-level evidence that midurethral mesh slings for stress incontinence are effective and safe; however, the rare but serious potential risks of this surgery must be discussed with the patient. The use of transvaginal mesh for prolapse repair does not appear to be supported by the current evidence, and its use should be restricted to specialized pelvic floor surgeons and specific clinical situations.

scholarly journals Peritoneal Dialysis for Chronic Congestive Heart Failure

2015 ◽  
Vol 40 (1) ◽  
pp. 45-52 ◽  
Author(s):  
Karlien François ◽  
Claudio Ronco ◽  
Joanne M. Bargman
Keyword(s):  
Heart Failure ◽  
Peritoneal Dialysis ◽  
Clinical Symptoms ◽  
Positive Impact ◽  
Cardiorenal Syndrome ◽  
Current Evidence ◽  
Chronic Congestive Heart Failure ◽  
Syndrome Type ◽  
Fluid Removal

Maladaptive responses between a failing heart and the kidneys ultimately lead to permanent chronic kidney disease, referred to as cardiorenal syndrome type 2. In this narrative review, we discuss the pathophysiological pathways in the progression of cardiorenal failure and review the current evidence on peritoneal dialysis as a treatment strategy in cardiorenal syndrome type 2. A patient with heart failure can present with clinical symptoms related to venous congestion even in the absence of end-stage renal disease. Diuretics remain the cornerstone for the treatment of fluid overload related to heart failure. However, with chronic use, diuretic resistance can supervene. When medical therapy is no longer able to relieve congestive symptoms, ultrafiltration might be needed. Patients with heart failure tolerate well the gentle rate of fluid removal through peritoneal dialysis. Recent publications suggest a positive impact of starting peritoneal dialysis in patients with cardiorenal syndrome type 2 on the hospitalisation rate, functional status and quality of life.

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

Fluid Re-Distributing Rather Than Fluid Removal Therapy as a Mainstay of Initial Heart Failure Treatment in Patients With Maintenance Hemodialysis

2017 ◽  
Vol 23 (10) ◽  
pp. S77
Author(s):  
Masaaki Konishi ◽  
Eiichi Akiyama ◽  
Yasushi Matsuzawa ◽  
Noriaki Iwahashi ◽  
Kazuo Kimura ◽  
...  
Keyword(s):  
Heart Failure ◽  
Maintenance Hemodialysis ◽  
Heart Failure Treatment ◽  
Fluid Removal ◽  
Failure Treatment

scholarly journals Interactions of adenoviruses with platelets and coagulation and the vaccine-associated autoimmune thrombocytopenia thrombosis syndrome

Haematologica ◽  
2021 ◽  
Author(s):  
Paolo Gresele ◽  
Stefania Momi ◽  
Rossella Marcucci ◽  
Francesco Ramundo ◽  
Valerio De Stefano ◽  
...  
Keyword(s):  
Time Course ◽  
Large Fraction ◽  
Vaccination Campaign ◽  
Adenovirus Vector ◽  
Epidemiological Studies ◽  
Coagulation System ◽  
Current Evidence ◽  
Cerebral Vein ◽  
Thrombotic Complications ◽  
Potential Risks

The Covid-19 pandemic has heavily impacted global health and economy and vaccination remains the primary way of controlling the infection. During the ongoing vaccination campaign some unexpected thrombotic events have emerged in subjects who recently received the AstraZeneca Vaxzevria vaccine or the Johnson&Johnson (Janssen) vaccine, two adenovirus vector-based vaccines. Epidemiological studies confirm that the observed/expected rate of these unusual thromboses is abnormally increased, especially in women in the fertile age. The characteristics of this complication, with venous thromboses at unusual sites, most frequently cerebral vein sinus but also splanchnic, often multiple associated thromboses, thrombocytopenia, and sometimes disseminated intravascular coagulation, are unique and the time course and tumultuous evolution are suggestive of an acute immunological reaction, and indeed platelet-activating anti-PF4 antibodies have been detected in a large fraction of the affected patients. Several data suggest that adenoviruses may interact with platelets, the endothelium and the blood coagulation system. Here we review the interactions between adenoviral vectors and the haemostatic system of possible relevance for the vaccine associated thrombotic thrombocytopenia syndrome, we analyse systematically the clinical data on the reported thrombotic complications of adenovirus-based therapeutics and discuss all the current hypotheses on the mechanisms triggering this novel syndrome. Although considering current evidence the benefit of vaccination clearly outweighs the potential risks, it is of paramount importance to fully unravel the mechanisms leading to the vaccine associated thrombotic thrombocytopenia syndrome and to identify prognostic factors through further research.

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