Clinical Use of Profiled Hemodialysis

Abstract

The new population on dialysis today consists mainly of high risk patients (the elderly, diabetics, etc.) with high cardiovascular scores, and such vascular pathology is the most important predisposing factor for the occurrence of a frequent intradialytic clinical complication, vascular instability syndrome, which covers a range of clinical problems. Recently a new dialysis technique, profiled hemodialysis (PHD), has been set up and proposed for routine use. PHD consists of the clinical use of preestablished individual dialysis profiles aimed at antagonizing the changes in intradialytic plasma osmolarity by continuous modulation of dialysate sodium concentration throughout the whole extracorporeal session. In particular, PHD aims at reducing the fall of plasma osmolarity in the first half of the session (when it is higher) by reducing the sodium removal rate through increasing its dialysate concentration while taking into account the desired individual sodium balance to be reached at the end of the session. In this work, we report clinical experience with PHD compared to standard hemodialysis with constant sodium dialysate (SHD) in terms of its efficacy to maintain a more stable intradialytic blood volume (BV) and more stable hemodynamics. The PHD used in this work has been implemented by a mathematical model for computing the individual dialysate sodium profile which we have recently validated (Ursino M, Coli L, La Manna G, Grilli Cicilioni M, Dalmastri V, Guidicissi A, Masotti P, Avanzolini G, Stefani S, Bonomini V. A simple mathematical model of intradialytic sodium kinetics: "in vivo" validation during hemodialysis with constant or variable sodium. Int J Artif Organs 1996;19:393-403.). Eleven uremic patients affected by hypotension at the beginning of dialysis treatment were studied. Each patient first underwent an SHD treatment and 1 week later a PHD treatment. The 2 extracorporeal sessions (one on SHD and the other on PHD) were performed in each individual patient under identical operative conditions including the sodium mass removal by the end of the session and the ultrafiltration rate. The crit line and Doppler echocardiography were used to determine BV, cardiac output (CO), and stroke volume (SV) throughout the sessions. The mean blood pressure (MBP) and heart rate (HR) were simultaneously monitored. PHD was associated with a more stable intradialytic BV and more stable hemodynamics compared to SHD. The higher stability of BV and cardiac function (in terms of SV and CO maintenance) which was obtained above all in the first half of the PHD session was associated with a higher stability of the MBP and the HR. This resulted in an enhancement in cardiovascular tolerance to ultrafiltration throughout the session in all tested patients. In contrast, SHD in the same patients was characterized by early significant changes in BV and cardiovascular parameters resulting in a significant decrease of the MBP and a significant increase of the HR throughout the session and also 1 h after the end of dialysis. Our resul...

Sodium and Fluid Modulation in Dialysis: New Approach

“…Recently we tried this technique again and observed fluid removal with better control of vascular instability and disequilibrium syndrome than in standard hemodialysis. Many authors used different profile models [16, 17, 18]; we used a profile model which we defined as ‘bell pattern’.…”

A Critical Review of Sodium Profiling for Hemodialysis

“…Determination of plasma sodium concentrations based on dialysis fluid conductivity measurements has also been reported (26,28,33,42,49). These noninvasive techniques allow automatic optimization of dialysis fluid sodium concentration and may, in the future, permit an exact removal of accumulated water and sodium—individual postdialysis dry weights and plasma water conductivities will be prescribed by the physician (28,32,33,42,49).…”

Optimization of dialysate sodium in sodium profiling haemodialysis

“…A number of authors believe that the sodium profiling haemodialysis causes ‘interdialytic’ discomforts more frequently than the conventional haemodialysis in spite of its success in preventing intradialytic hypotensive episodes. In the review of previous studies, clinical or laboratory signs of sodium accumulation were found in eight studies, 2,3,7 , 8,34 , 39,40 ,41 but not in the other eight cases 4,37 , 42–47 . In one exceptional study in which the sodium was profiled from 137 to 128 mmol/L, the decreases of serum sodium levels, thirst, and interdialytic weight gain were observed 43 .…”