Ultrasound-based clinical profiles for predicting the risk of intradialytic hypotension in critically ill patients on intermittent dialysis: a prospective observational study

Abstract

BackgroundIntradialytic hypotension, a complication of intermittent hemodialysis, decreases the efficacy of dialysis and increases long-term mortality. This study was aimed to determine whether different predialysis ultrasound cardiopulmonary profiles could predict intradialytic hypotension.MethodsThis prospective observational single-center study was performed in 248 critically ill patients with acute kidney injury undergoing intermittent hemodialysis. Immediately before hemodialysis, vena cava collapsibility was measured by vena cava ultrasound and pulmonary congestion by lung ultrasound. Factors predicting intradialytic hypotension were identified by multiple logistic regression analysis.ResultsIntradialytic hypotension was observed in 31.9% (n = 79) of the patients, interruption of dialysis because of intradialytic hypotension occurred in 6.8% (n = 31) of the sessions, and overall 28-day mortality was 20.1% (n = 50). Patients were classified in four ultrasound profiles: (A) 108 with B lines > 14 and vena cava collapsibility > 11.5 mm m−2, (B) 38 with B lines < 14 and vena cava collapsibility ≤ 11.5 mm m−2, (C) 36 with B lines > 14 and vena cava collapsibility Di ≤ 11.5 mm m−2, and (D) 66 with B lines < 14 and vena cava collapsibility > 11.5 mm m−2. There was an increased risk of intradialytic hypotension in patients receiving norepinephrine (odds ratios = 15, p = 0.001) and with profiles B (odds ratios = 12, p = 0.001) and C (odds ratios = 17, p = 0.001).ConclusionIn critically ill patients on intermittent hemodialysis, the absence of hypervolemia as assessed by lung and vena cava ultrasound predisposes to intradialytic hypotension and suggests alternative techniques of hemodialysis to provide better hemodynamic stability.

Intradialytic Hypotension in Critically Ill Patients on Hemodialysis With A-Line versus B-Line Pattern on Lung Ultrasonography

“…In conclusion, we found that among ICU patients receiving dialysis, those with A-line pattern were more likely to experience IDH than those with B-line pattern on POCUS. Our data build on other research, 5 showing a strong signal that LUS findings can predict IDH, and can potentially be used to better personalize dialysis ultrafiltration prescription. These findings need to be corroborated by additional prospective studies to examine the impact on clinical practice.…”

“…Prior research has shown the utility of LUS in identifying patients at risk of IDH. In a study by de Hora Passos et al 5 using 28-point LUS on 248 critically ill patients requiring kidney replacement therapy, patients with more than 14 B-lines were characterized as having pulmonary congestion. Almost half (48%) of patients with pulmonary congestion experienced IDH, compared with 67% without pulmonary congestion.…”

“…Almost half (48%) of patients with pulmonary congestion experienced IDH, compared with 67% without pulmonary congestion. 5 As a comprehensive 28-point LUS study can take between 6 and 15 minutes, 6 its utility in clinical practice may remain limited. Our findings that patients with Aline pattern are more likely to experience IDH are congruent with the report of de Hora Passos et al, 5 yet may be more clinically applicable.…”

“…5 As a comprehensive 28-point LUS study can take between 6 and 15 minutes, 6 its utility in clinical practice may remain limited. Our findings that patients with Aline pattern are more likely to experience IDH are congruent with the report of de Hora Passos et al, 5 yet may be more clinically applicable. Indeed, our findings support clinical practice guidelines that recommend 8point LUS to qualitatively characterize lung pathology, whereas many research studies focus on quantifying the number of B-lines.…”

Prediction of Hemodynamic Tolerance of Intermittent Hemodialysis in Critically Ill Patients: A Cohort Study

“…Intradialytic hypotension is a common complication associated with RRT; it may be associated with the ultra ltration rate and can cause further ischemic injury to the recovering kidneys, thereby potentially reducing the probability of renal recovery [4,8]. Therefore, the selection of the optimal ultra ltration rate that will not result in any adverse clinical consequences depends on an accurate estimation of the patient's uid status and hemodynamics, an adequate understanding of the principles of uid overload treatment with ultra ltration, and clear treatment goals [2,9,10].…”