Cerebral ischemia during hemodialysis—finding the signal in the noise

MacEwen, Clare; Watkinson, Peter; Tarassenko, Lionel; Pugh, Christopher W.

doi:10.1111/sdi.12679

Cited by 11 publications

(12 citation statements)

References 58 publications

(122 reference statements)

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“…This is supported by the positive correlation of cfDNA post-HD with NLR. Organ ischemia which could occur during HD, such as cerebral ischemia and/or myocardial stunning might also contribute to an increase in cfDNA [27,28]. This is supported by the positive correlation between CVD and cfDNA concentration post-HD, as opposed to cfDNA pre-HD, as demonstrated in our study.…”

Section: Discussionsupporting

confidence: 86%

Elevated Circulating Cell-Free DNA in Hemodialysis-Treated Patients Is Associated with Increased Mortality

et al. 2020

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Background: Predicting the mortality risk of patients undergoing hemodialysis (HD) is challenging. Cell-free DNA (cfDNA) is released into circulation from dying cells, and its elevation is predictive of unfavorable outcome. In a pilot study, we found post-HD cfDNA level to be a predictor of all-cause mortality. Thus, the aim of this study was to confirm the prognostic power of cfDNA in a larger prospective cohort study conducted at 2 medical centers. Methods: CfDNA levels were measured by a rapid fluorometric assay on sera obtained before and after 1 HD session. One hundred fifty-three patients were followed up to 46 months for mortality during which time 47 patients died. We compared the predictive value of cfDNA to age, comorbidities, and standard blood tests. Results: Examining standard blood tests, only post-HD cfDNA levels were elevated in the non-survivor group compared to survivors (959 vs. 803 ng/mL, p = 0.04). Pre- and post-HD cfDNA levels correlated with age and diabetes. Patients with elevated cfDNA (>850 ng/mL) showed lower survival than those with normal levels. A Cox proportional hazard regression model demonstrated a significant hazard ratio of 1.92 for post-HD cfDNA levels. Logistic regression models showed that post-HD cfDNA was a significant predictor of mortality at 1–3 years with odd ratios of 4.61, 4.36, and 6.22, respectively. Conclusions: Post-HD cfDNA level was superior to standard blood tests and could serve as a biomarker to assist in decision-making for HD-treated patients.

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Section: Discussionsupporting

confidence: 86%

Elevated Circulating Cell-Free DNA in Hemodialysis-Treated Patients Is Associated with Increased Mortality

et al. 2020

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“…For the analysis of rSO 2, we excluded values of zero and excluded rSO 2 values with a quality score <4, to increase accuracy and exclude movement artifacts. Mean rSO 2 values were calculated for the 5-min time periods during which the three [ 15 To define regional CBF, we also performed magnetic resonance imaging (MRI) in all patients using a 1.5T whole body system (Aera, Siemens, Erlangen, Germany) on a separate day. The scan protocol included T1-weighted, T2-weighted, three-dimensional fluid-attenuated inversion recovery, diffusion-weighted imaging, susceptibility weighted imaging, and twodimensional phase contrast sequences.…”

Section: Nirs Monitoring and Analysismentioning

confidence: 99%

“…Therefore, there is a need for an alternative method that is easier to apply to monitor changes in cerebral perfusion during hemodialysis. 15…”

Section: Introductionmentioning

confidence: 99%

Changes in cerebral oxygenation and cerebral blood flow during hemodialysis – A simultaneous near-infrared spectroscopy and positron emission tomography study

Polinder-Bos

Elting

Aries

et al. 2018

J Cereb Blood Flow Metab

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Near-infrared spectroscopy (NIRS) is used to monitor cerebral tissue oxygenation (rSO 2 ) depending on cerebral blood flow (CBF), cerebral blood volume and blood oxygen content. We explored whether NIRS might be a more easy applicable proxy to [ 15 O]H 2 O positron emission tomography (PET) for detecting CBF changes during hemodialysis. Furthermore, we compared potential determinants of rSO 2 and CBF. In 12 patients aged ! 65 years, NIRS and PET were performed simultaneously: before (T1), early after start (T2), and at the end of hemodialysis (T3). Between T1 and T3, the relative change in frontal rSO 2 (DrSO 2 ) was À8 AE 9% (P ¼ 0.001) and À5 AE 11% (P ¼ 0.08), whereas the relative change in frontal gray matter CBF (DCBF) was À11 AE 18% (P ¼ 0.009) and À12 AE 16% (P ¼ 0.007) for the left and right hemisphere, respectively. DrSO 2 and DCBF were weakly correlated for the left (r 0.31, P ¼ 0.4), and moderately correlated for the right (r 0.69, P ¼ 0.03) hemisphere. The Bland-Altman plot suggested underestimation of DCBF by NIRS. Divergent associations of pH, pCO 2 and arterial oxygen content with rSO 2 were found compared to corresponding associations with CBF. In conclusion, NIRS could be a proxy to PET to detect intradialytic CBF changes, although NIRS and PET capture different physiological parameters of the brain.

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“…However, even in the absence of symptoms, HD may lead to reduction in tissue perfusion, which is likely related to persistent damage in vital organs such as the heart and brain . This may also occur with falls in BP during HD that are generally considered too small to be of clinical concern . Oxygen delivery to the tissues may be further aggravated by the presence of intradialytic hypoxemia, which is present in a substantial percentage of patients and associated with increased mortality.…”

Section: Interactions Between Circulatory Thermal and Respiratory Stmentioning

confidence: 99%

Hemodialysis: A model for extreme physiology in a vulnerable patient population

Kooman

Katzarski

Sande

et al. 2018

Seminars in Dialysis

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Hemodialysis (HD) is a lifesaving treatment for patients with end-stage renal disease, which is very efficient in the correction of abnormalities of the internal environment. However, this efficiency also induces significant hemodynamic, thermal, and respiratory stressors. These have parallels with the extreme physiologic demands which are normally mainly experienced by healthy subjects under adverse environmental conditions, with the difference that they must be endured by a vulnerable patient population. Hemodynamic stress induced by ultrafiltration leads to a decline in circulating blood volume, which may result in intradialytic hypotension (IDH) and changes in tissue perfusion, which may have long-term consequences for the function of vital organs such as the brain and the heart. Pronounced declines in central venous oxygen saturation have been observed during routine HD, which are related to the circulatory stress imposed upon the patient. Apart from patient-related factors, thermal stress induced by HD may lead to skin vasodilation, counteracting the normal hemodynamic response to hypovolemia, which has important pathophysiologic correlates in heat syncope. Lastly, respiratory stress is reflected by prolonged arterial hypoxemia during HD, which is both related to patient-related factors, but may also be partly because of the treatment itself, especially during the first 30-60 minutes. Whereas hypoxemia during HD is related to increased mortality, its role in the reduced tissue oxygen delivery during HD should be further defined. Treatment modifications, such as cool or temperature-controlled HD, may reduce circulatory and thermal stress, which also may translate into a reduced risk of long-term cardiac or cerebral damage. However, as circulatory stress is mainly time-dependent, prolonged, or more dialysis treatment may reduce the homeostatic burden on the patient.

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Cerebral ischemia during hemodialysis—finding the signal in the noise

Cited by 11 publications

References 58 publications

Elevated Circulating Cell-Free DNA in Hemodialysis-Treated Patients Is Associated with Increased Mortality

Elevated Circulating Cell-Free DNA in Hemodialysis-Treated Patients Is Associated with Increased Mortality

Changes in cerebral oxygenation and cerebral blood flow during hemodialysis – A simultaneous near-infrared spectroscopy and positron emission tomography study

Hemodialysis: A model for extreme physiology in a vulnerable patient population

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