Impact of sodium and ultrafiltration profiling on haemodialysis-related hypotension

Zhang, Yi; Liu, Hui Lan; Duan, Xiyu; Yao, Ying; Sun, Yi; Li, Qun

doi:10.1093/ndt/gfl375

Cited by 81 publications

(81 citation statements)

References 22 publications

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“…As of yet, the benefits of sodium profiles with a neutral sodium balance remain unclear. However, decreased hypotensive episodes have been observed in short-term studies when neutral sodium balance profiles were combined with ultrafiltration profiles [41,42] .…”

Section: Avoidance Of Inappropriate Sodium Profilingmentioning

confidence: 99%

Improving Volume Status by Comprehensive Dietary and Dialytic Sodium Management in Chronic Hemodialysis Patients

2010

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Chronic volume overload is highly prevalent in chronic hemodialysis patients and leads to hypertension, left ventricular hypertrophy and increased hospitalization and mortality rates. Volume overload is caused primarily by a positive sodium balance and can be improved by sodium restriction. The main sources of sodium excess are a high-sodium diet in the interdialytic period and a positive sodium balance during dialysis. Here we discuss different approaches to achieve neutral or negative sodium balance, including reducing dietary sodium intake, individualizing dialysate sodium prescription, abandonment of sodium profiling, and reducing saline infusion for treatment of intradialytic symptoms and as part of dialyzer rinsing and priming procedures. All of these approaches should be combined for a maximal reduction of volume overload.

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Section: Avoidance Of Inappropriate Sodium Profilingmentioning

confidence: 99%

Improving Volume Status by Comprehensive Dietary and Dialytic Sodium Management in Chronic Hemodialysis Patients

2010

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“…8 Because symptom and intervention data are often unavailable in large databases, some IDH definitions are based exclusively on SBP measurements, such as SBP reduction by some requisite amount during treatment (20,30, and 40 mmHg) or nadir intradialytic SBP below a threshold value (90, 95, and 100 mmHg). [9][10][11][12][13] Compound definitions are also common; examples include $30-mmHg SBP fall+nadir SBP,110 mmHg and $20-mmHg SBP fall+fluid bolus6symptoms. 14,15 Discrepancies in IDH definitions limit synthesis of the existing data regarding putative IDH sequelae and potential strategies for IDH prophylaxis and treatment.…”

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confidence: 99%

Association of Mortality Risk with Various Definitions of Intradialytic Hypotension

Flythe

Hou

Lynch

et al. 2015

Journal of the American Society of Nephrology

357

386

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Intradialytic hypotension is a serious and frequent complication of hemodialysis; however, there is no evidence-based consensus definition of intradialytic hypotension. As a result, coherent evaluation of the effects of intradialytic hypotension is difficult. We analyzed data from 1409 patients in the HEMO Study and 10,392 patients from a single large dialysis organization to investigate the associations of commonly used intradialytic hypotension definitions and mortality. Intradialytic hypotension definitions were selected a priori on the basis of literature review. For each definition, patients were characterized as having intradialytic hypotension if they met the corresponding definition in at least 30% of baseline exposure period treatments or characterized as control otherwise. Overall and within subgroups of patients with predialysis systolic BP,120 or 120-159 mmHg, an absolute nadir systolic BP,90 mmHg was most potently associated with mortality. Within the subgroup of patients with predialysis BP$160 mmHg, nadir BP,100 mmHg was most potently associated with mortality. Intradialytic hypotension definitions that considered symptoms, interventions, and decreases in BP during dialysis were not associated with outcome, and when added to nadir BP, symptom and intervention criteria did not accentuate associations with mortality. Our results suggest that nadir-based definitions best capture the association between intradialytic hypotension and mortality.

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“…Recent studies suggest this approach is particularly effective when combined with sodium modeling. 7,8 Devices to monitor intradialytic changes in blood volume have been advocated as a tool to minimize intradialytic hypotension on the basis of the concept that the likelihood of developing hypotension will always occur at roughly the same reduction of blood volume. Unfortunately, most studies have not found a close relationship between individual changes in blood volume and occurrence of hypotension.…”

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confidence: 99%

Recent Advances in the Prevention and Management of Intradialytic Hypotension

Palmer

Henrich

2008

Journal of the American Society of Nephrology

158

124

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A symptomatic reduction in BP during or immediately after dialysis occurs in approximately 20 to 30% of dialysis sessions. The treatment includes stopping or slowing the rate of ultrafiltration, placing the patient in the Trendelenburg position, decreasing the blood flow rate, and restoring intravascular volume. Such episodes predispose the patient to leave the dialysis unit volume overloaded and if repetitive can lead to inadequate clearance. Intradialytic hypotension and orthostatic hypotension after the procedure are significant and independent risk factors affecting mortality in dialysis patients. 1 This clinical commentary focuses on recent advances in the prevention and management of intradialytic hypotension.Dialysis hypotension is the result of an inadequate cardiovascular response to the reduction in blood volume that occurs when a large volume of water is removed during a short period of time. In a typical dialysis procedure, an ultrafiltrate volume that is equal to or greater that the entire plasma volume is often removed.Despite the large ultrafiltrate volume, plasma volume typically decreases by only approximately 10 to 20%. This ability to maintain plasma volume during ultrafiltration requires mobilization of fluid from the interstitial into the intravascular space. Vascular refilling is influenced by both patient-specific and treatment-related factors that dictate the distribution of water between the body fluid compartments.The amount of interstitial fluid available for vascular refilling is influenced by the dry weight set for the patient. When the volume of interstitial fluid is small, any ultrafiltrate volume will more likely be associated with hemodynamic instability. This explains the development of hypotension when patients undergo dialysis below their true dry weight. By contrast, increased amounts of interstitial fluid will expand the volume of fluid accessible for refilling of the intravascular space and, therefore, decrease the likelihood of hypotension. In most patients, a dry weight that minimizes the amount of interstitial fluid present is selected because chronic volume overload has long-term deleterious effects on the cardiovascular system.The determination of dry weight is largely assessed empirically by trial and error. The dry weight is set at the weight below which unacceptable symptoms, such as cramping, nausea, and vomiting, or hypotension occur. The dry weight is highly variable in many patients and can fluctuate with intercurrent illnesses (e.g., diarrhea, infection) and with changes in hematocrit (as with erythropoietin). A number of methods have been proposed to define more objectively the dry weight of the patient (Table 1). Comparative studies have generally favored methods based on bioimpedance measurements, which provide an assessment of extracellular and intracellular volume and total body water. 2-4 A variant of this technique in which continuous intradialytic measurements are confined to the calf shows particular promise because the relative volume of excess extrac...

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Impact of sodium and ultrafiltration profiling on haemodialysis-related hypotension

Cited by 81 publications

References 22 publications

Improving Volume Status by Comprehensive Dietary and Dialytic Sodium Management in Chronic Hemodialysis Patients

Improving Volume Status by Comprehensive Dietary and Dialytic Sodium Management in Chronic Hemodialysis Patients

Association of Mortality Risk with Various Definitions of Intradialytic Hypotension

Recent Advances in the Prevention and Management of Intradialytic Hypotension

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