Intradialytic Hypoxemia and Clinical Outcomes in Patients on Hemodialysis

Meyring-Wösten, Anna; Zhang, Hanjie; Ye, Xiaoling; Fuertinger, Doris; Chan, Lili; Kappel, Franz; Artemyev, Mikhail; Ginsberg, Nancy; Wang, Yuedong; Thijssen, Stephan; Kotanko, Peter

doi:10.2215/cjn.08510815

Cited by 68 publications

(95 citation statements)

References 47 publications

(43 reference statements)

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“…Low intradialytic SaO 2 has been linked to peridialytic hypertension [26], a factor implicated in excess mortality [27,28]. Recently, prolonged intradialytic hypoxemia (defined as SaO 2 < 90% for more than 1/3 of the treatment time) has been associated with an inflammatory phenotype, hospitalization, and all-cause mortality [29]. Against this background, it is conceivable that low SaO 2 may play a causal role in the development of low and unstable ScvO 2 .…”

Section: Discussionmentioning

confidence: 99%

Association of Central Venous Oxygen Saturation Variability and Mortality in Hemodialysis Patients

et al. 2018

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Background: Central venous oxygen saturation (ScvO₂) is correlated with cardiac output. In most patients, ScvO₂ declines during hemodialysis (HD) due to factors such as reduced preload, myocardial stunning, and intermittent arrhythmias. Previous research has shown that low ScvO₂ is associated with higher mortality in chronic HD patients. In this research, we tested the hypothesis that ScvO₂ variability is associated with all-cause mortality. Methods: We conducted a retrospective study in 232 chronic HD patients with central venous catheter as vascular access. ScvO₂ was recorded 1× per minute during dialysis using the Crit-Line monitor. A 6-month baseline comprising at least 10 dialysis treatments with ScvO₂ recordings preceded a follow-up period of up to 3 years. The coefficient of variation (CV) of ScvO₂ (100 times the ratio of the standard deviation and mean of ScvO₂) served as a measure of ScvO₂ stability during baseline. Patients were stratified by median population CV of ScvO₂ during baseline, and survival during follow-up was compared between the 2 groups by Kaplan Meier and multivariate Cox analysis. The association between CV of ScvO₂ and all-cause mortality during follow-up was further assessed by Cox analysis with a spline term for CV of ScvO₂. Results: The mean CV ± standard deviation of ScvO₂ in our population was 6.1 ± 2.7% and the median was 5.3%. Univariate Kaplan-Meier analysis (p = 0.043) and multivariate Cox analysis (hazard ratio [HR] 1.16; p = 0.0005) indicated that a CV of ScvO₂ > 5.3% was significantly associated with increased mortality. In Cox analysis with spline term, a CV of ScvO₂ > 11% was associated with a significantly increased HR for all-cause mortality. Conclusion: High ScvO₂ variability during dialysis is associated with increased all-cause mortality.

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Section: Discussionmentioning

confidence: 99%

Association of Central Venous Oxygen Saturation Variability and Mortality in Hemodialysis Patients

et al. 2018

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“…The Crit-Line Monitor simultaneously measures the oxygen saturation and hemoglobin concentration, so that the dynamic hemoglobin changes can be factored into the calculation. Concurrent measurements of SaO 2 would be highly desirable because SaO 2 can change throughout HD [28,29]. We recognize the absence of SaO 2 measurements as a limitation, and efforts to remedy this are underway.…”

Section: Discussionmentioning

confidence: 99%

“…In our study, we obtained ScvO 2 and Hgb noninvasively using the Crit-Line Monitor. In the absence of SaO 2 measurements, we assumed a constant value of 92.6% for every patient, which was recently described to be the average SaO2 in a large population of HD patients [28]. It is important to appreciate that relative changes in ScvO 2 and eUBBF appear to be more informative than their absolute values, mitigating concerns that the calculation of eUBBF is based on patient-specific assumptions that may be difficult to ascertain in clinical practice.…”

Section: Discussionmentioning

confidence: 99%

Tracking Arteriovenous Fistula Maturation: A Novel Approach

et al. 2018

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Background: The time between the creation of an arteriovenous fistula (AVF) and its successful use is significantly longer in hemodialysis (HD) patients in the United States compared to those in other countries, and there is an urgent need to reduce the residence time of central-venous catheters (CVC). Methods: Successful AVF creation and maturation results in typical hemodynamic changes, such as an increase in cardiac output and upper body blood flow (UBBF). In patients with CVC as vascular access, we measured once per minute intradialytic central-venous oxygen saturation (ScvO₂) and hemoglobin levels simultaneously using the Crit-Line Monitor. Under conditions of stable upper body oxygen consumption and arterial oxygen saturation, ScvO₂ and hemoglobin concentration allows the calculation of estimated UBBF (eUBBF). In a quality improvement project, we used ScvO₂ and eUBBF to track the hemodynamic changes accompanying AVF maturation. Results: Out of 11 patients (9 incident to HD, 1 female, age 61 ± 13 years), AVF maturation was successful in 9. In 1 patient, the AVF did not mature. One patient died from sudden cardiac death with a maturing AVF. In the 9 patients with successful AVF maturation, ScvO₂ increased from 60.9 ± 2.7% prior to AVF creation to 73.4 ± 3.6% a week after AVF creation (19.6 ± 6.3% increase). eUBBF increased from 1.3 ± 0.3 to 2.2 ± 0.6 L/min (62.7 ± 37.5% increase); no material ScvO₂ or eUBBF changes occurred in the other 2 patients. Conclusion: Our results indicate the potential utility of ScvO₂ and eUBBF to track the hemodynamic response to AVF maturation. To what extent these insights translate into shortening of the time between AVF creation and successful cannulation warrants further investigations.

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“…About half of HD patients in the United States are dialyzed in ≥37 mEq/L dialysate (HCO 3 – ) [34], while 83% of HD patients in Japan are dialyzed with dialysate (HCO 3 – ) of <30 mEq/L [35]. Metabolic alkalosis due to the high dialysate (HCO 3 – ) has been associated with the occurrence of cardiac arrhythmia, intradialytic hypocalcemia, hypokalemia, hypercapnia, hypoxia, intradialytic hypotension, and vascular calcification [36, 37]. In patients with chronic obstructive pulmonary disease (COPD) or other causes of ventilator impairment, higher dialysate (HCO 3 – ) can cause CO 2 accumulation and potentiate hypoxia.…”

Section: Acid-base Electrolyte and Volume Derangements In Esrdmentioning

confidence: 99%

Acid-Base and Electrolyte Managements in Chronic Kidney Disease and End-Stage Renal Disease: Case-Based Discussion

et al. 2018

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Acid-base and electrolyte alterations are common in patients with chronic kidney disease (CKD) and end-stage kidney failure (ESRD). The alterations become more complex as CKD advances to ESRD, leading to morbidity and mortality. Three cases are presented illustrating some key prototypic features in CKD and ESRD. Each is accompanied by discussion of pathophysiology, diagnosis, and treatment options. Newer investigational results are integrated into the existing body of knowledge. Although rigorous assessment of various dialysis prescriptions is scanty, in its current state, instituting a well thought-out, multi-pronged management plan to minimize CKD/ESRD and dialysis-related electrolyte and acid-base disruptions is appropriate. There is a pressing need for prospective interventional trials in the future.

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Intradialytic Hypoxemia and Clinical Outcomes in Patients on Hemodialysis

Cited by 68 publications

References 47 publications

Association of Central Venous Oxygen Saturation Variability and Mortality in Hemodialysis Patients

Association of Central Venous Oxygen Saturation Variability and Mortality in Hemodialysis Patients

Tracking Arteriovenous Fistula Maturation: A Novel Approach

Acid-Base and Electrolyte Managements in Chronic Kidney Disease and End-Stage Renal Disease: Case-Based Discussion

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