Measurement of Cardiac Output and Blood Volume During Hemodialysis with Fluorescent Dye Dilution Technique

Abstract

Intradialytic hypotensive events (IDH) accompanied by deleterious decreases of the cardiac output complicate up to 25% of hemodialysis treatments. Monitoring options available to track hemodynamic changes during hemodialysis have been found ineffective to anticipate the occurrence of IDH. We have assembled opto-electronic instrumentation that uses the fluorescence of a small bolus of indocyanine green dye injected in the hemodialysis circuit to estimate cardiac output and blood volume based on indicator dilution principles in patients receiving hemodialysis. The instrument and technique were tested in 24 adult end-stage renal failure subjects during 64 hemodialysis sessions. A single calibration factor could be used across subjects and across time. Intra-subject variability of the measurements over time was <10%. Stroke volume index (SVI) (mean ± SEM = 34 ± 1 vs. 39 ± 2 mL m) and central blood volume (CBV) index (783 ± 36 vs. 881 ± 33 mL m) were lower at the beginning of the sessions in which IDH eventually occurred. Cardiac index, SVI, and CBV index decreased with hemodialysis in all treatment sessions but the decrease was more intense in the IDH sessions. We conclude that hemodynamic monitoring can be implemented in patients receiving hemodialysis with minimal disruption of the treatment and could help understand intradialytic hypotension.

Intravascular volumes evaluated by a carbon monoxide rebreathing method in patients undergoing chronic hemodialysis

“…Current techniques for measuring intravascular volume include dialysate infusion using ΔRBC, fluorescent dye dilution techniques, or radioactive labeled erythrocytes and albumin . The CO rebreathing test avoids using radiation and can be performed independently of hemodialysis.…”

“…These methods are used to various degrees in the clinical setting, but no single method has had a proven substantial effect on survival. For measuring intravascular volumes, current techniques include dialysate infusion using relative blood volume changes (ΔRBC), fluorescent dye dilution techniques, and radioactive labeling of erythrocytes and albumin . However, these techniques are primarily used in research, and their clinical use in hemodialysis patients is limited.…”

Hemodialysis Ultrafiltration Rate Targets Should Be Scaled to Body Surface Area Rather than to Body Weight

“…A reasonable physiologic rationale exists for scaling UF rate to blood volume, since it has been argued that intradialytic hypotension (IDH) tends to occur once a unique critical blood volume is reached (15)(16)(17)(18)(19)(20). However, this argument probably is too simplistic, since there is also evidence that the splanchnic circulation importantly contributes to intradialytic hemodynamic stability (21,22) and IDH may occur due to inadequate shifting of blood from compliant splanchnic veins to the central blood volume.…”

Changes in cardiac output with hemodialysis relate to net volume balance and to inferior vena cava ultrasound collapsibility in critically ill patients

“…CO has been reported to decrease >10% after intermittent HD and/or UF in multiple studies of stable ESRD patients with or without a propensity for intradialytic hypotension (IDH) [8,[13][14][15][16][17][18][19][20][21][22][23][24][25][26][27]. CO has been reported to be decreased in critically ill patients with acute hepatic and renal failure receiving vasopressors during intermittent hemodiafiltration without net UF [28], in patients with AKI associated with critical illnesses during HD with or without UF [29], and with sepsis and acute kidney injury (AKI) during continuous veno-venous hemofiltration (CVVH) without UF [30].…”

“…Intradialytic hypotension (IDH) may relate to cardiac stunning and decreased CO in stable ESRD patients [25,26], and may limit the volume of net UF removed in critically ill patients [5].…”