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Introduction Online hemodiafiltration (OL-HDF) is the most effective renal replacement therapy (RRT), which allows the enhanced removal of small and large uremic toxins by combining diffusion and convective transport of solutes. Although the goal of OL-HDF is to provide greater clearance of solutes with a preference for intermediate molecules responsible for many of the complications of chronic kidney disease (CKD), the studies reported to date and their meta-analyses are conflicting in nature and do not show a significant advantage of convective therapies on patient prognosis. Materials and methods At the Clinic of Nephrology and Dialysis, University Hospital "St. Marina", Varna, Bulgaria, 41 patients were monitored in a retrospective study for a two-year period, randomized into two groups, conducting OL-HDF after dilution and hemodialysis (HD) with the aim of studying the effect of convective therapies on the clinical outcome, the achieved quality of life, and the prognosis of the patient. Results The study found a significantly higher quality of life in patients undergoing OL-HDF with significantly higher values ​​of indicators of dialysis adequacy and nutritional status, better control of the anemic syndrome with the reduction of erythropoietin doses, significantly lower frequency of episodes of intradialytic hypotension with improved recovery, and 3.6-fold lower risk of death compared with conventional dialysis. Discussion Three major randomized controlled trials have compared survival outcomes in patients receiving HD or post-dilution OL-HDF, reporting conflicting results. Meta-analyses of the published studies have also been unable to provide a clear and definitive answer regarding the potential benefits of choosing one treatment over the other. Overall mortality, anemia, phosphate control, and small molecule clearance appear to be insufficiently influenced by the treatment method. On the other hand, cardiovascular mortality, hemodynamic stability, and clearance of middle and protein-bound molecules seem to be better in patients treated with OL-HDF. Conclusions Despite the conflicting data reported so far, OL-HDF is associated with better clinical outcome and prognosis for end-stage renal disease (ESRD) patient and undoubtedly warrants extensive future study with a view to improved quality of life in the growing dialysis population.

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Intradialytic hypotension (IDH) is a common and potentially life-threatening complication in hemodialysis patients. Traditional preventive measures have shown limited effectiveness in reducing IDH incidence. This systematic review evaluates the existing literature on the use of artificial intelligence (AI) and machine learning (ML) models for predicting IDH in hemodialysis patients. A comprehensive literature search identified five eligible studies employing diverse AI/ML algorithms, including artificial neural networks, decision trees, support vector machines, XGBoost, random forests, and LightGBM. These models utilized various features such as patient demographics, clinical data, laboratory findings, and dialysis-related parameters. The studies reported promising results, with several models achieving high prediction accuracies, sensitivities, specificities, and area under the receiver operating characteristic curve values for predicting IDH. However, limitations include variations in study populations, retrospective designs, and the need for prospective validation. Future research should focus on multicenter prospective studies, assessing clinical utility, and integrating interpretable AI/ML models into clinical decision support systems.

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While life-sustaining, hemodialysis is a non-physiological treatment modality that exerts stress on the patient, primarily due to fluid shifts during ultrafiltration. Automated feedback control systems, integrated with sensors that continuously monitor bio-signals such as blood volume, can adjust hemodialysis treatment parameters, e.g., ultrafiltration rate, in real-time. These systems hold promise to mitigate hemodynamic stress, prevent intradialytic hypotension, and improve the removal of water and electrolytes in chronic hemodialysis patients. However, robust evidence supporting their clinical application remains limited. Based on an extensive literature research, we assess feedback-controlled ultrafiltration systems that have emerged over the past three decades in comparison to conventional hemodialysis treatment. We identified 28 clinical studies. Closed loop ultrafiltration control demonstrated effectiveness in 23 of them. No adverse effects of closed loop ultrafiltration control were reported across all trials. Closed loop ultrafiltration control represents an important advancement towards more physiological hemodialysis. Its development is driven by innovations in real-time bio-signals monitoring, advancement in control theory, and artificial intelligence. We expect these innovations will lead to the prevalent adoption of ultrafiltration control in the future, provided its clinical value is substantiated in adequately randomized controlled trials.

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Diálisis Renal , Ultrafiltración , Humanos , Diálisis Renal/métodos , Ultrafiltración/métodos , Retroalimentación

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BACKGROUND AND AIMS: Intradialytic eating practices is a subject of debate among hemodialysis patients and is associated with a variety of clinical implications. This study aimed to investigate eating practices during hemodialysis and their influence on health outcome, including various symptoms experienced during dialysis, intradialytic hypotension, dialysis adequacy, and malnutrition. METHODS: A cross-sectional study was conducted on hemodialysis patients. A structured questionnaire was used to collect information related to sociodemographic, medical history, lifestyle, dialysis, and eating practices. The occurrence of intradialytic hypotension was determined according to the patients' blood pressure measured at the beginning and end of the session, and dialysis adequacy was determined based on the ultrafiltration rate of the patients. Malnutrition was evaluated using renal inpatient screening tool (renal iNUT), and biochemical data was recruited from the patient's hospital records. RESULTS: A total of 260 hemodialysis patients participated in this study. The mean age was 51.29 ± 15.92, and half of the participants were females. The findings showed no significant association between intradialytic eating practices and symptoms developed during dialysis session, intradialytic hypotension, or malnutrition (p > 0.05). According to Chi-square test, a statistically significant association was found between eating practices and dialysis adequacy (p = 0.037), hemoglobin level (p < 0.001), and phosphorous level (p = 0.003). CONCLUSION: Eating practices were not associated with symptoms that developed during dialysis sessions, intradialytic hypotension, or malnutrition, according to our findings. However, findings reveal that it is possible that eating practices may affect the adequacy of dialysis.

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BACKGROUND: Intradialytic hypotension (IDH) is one of the most common and critical complications of hemodialysis. Despite many proven factors associated with IDH, accurately predicting it before it occurs for individual patients during dialysis sessions remains a challenge. PURPOSE: To establish artificial intelligence (AI) predictive models for IDH, which consider risk factors from previous and ongoing dialysis to optimize model performance. We then implement a novel digital dashboard with the best model for continuous monitoring of patients' status undergoing hemodialysis. The AI dashboard can display the real-time probability of IDH for each patient in the hemodialysis center providing an objective reference for care members for monitoring IDH and treating it in advance. METHODS: Eight machine learning (ML) algorithms, including Logistic Regression (LR), Random Forest (RF), Support Vector Machine (SVM), K Nearest Neighbor (KNN), Light Gradient Boosting Machine (LightGBM), Multilayer Perception (MLP), eXtreme Gradient Boosting (XGBoost), and NaiveBayes, were used to establish the predictive model of IDH to determine if the patient will acquire IDH within 60 min. In addition to real-time features, we incorporated several features sourced from previous dialysis sessions to improve the model's performance. The electronic medical records of patients who had undergone hemodialysis at Chi Mei Medical Center between September 1, 2020 and December 31, 2020 were included in this research. Impact evaluation of AI assistance was conducted by IDH rate. RESULTS: The results showed that the XGBoost model had the best performance (accuracy: 0.858, sensitivity: 0.858, specificity: 0.858, area under the curve: 0.936) and was chosen for AI dashboard implementation. The care members were delighted with the dashboard providing real-time scientific probabilities for IDH risk and historic predictive records in a graphic style. Other valuable functions were appended in the dashboard as well. Impact evaluation indicated a significant decrease in IDH rate after the application of AI assistance. CONCLUSION: This AI dashboard provides high-quality results in IDH risk prediction during hemodialysis. High-risk patients for IDH will be recognized 60 min earlier, promoting individualized preventive interventions as part of the treatment plan. Our approachis believed to promise an excellent way for IDH management.

Asunto(s)

Hipotensión , Diálisis Renal , Humanos , Diálisis Renal/efectos adversos , Hipotensión/etiología , Factores de Riesgo , Femenino , Masculino , Persona de Mediana Edad , Inteligencia Artificial , Algoritmos , Anciano , Aprendizaje Automático , Máquina de Vectores de Soporte

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Intradialytic hypotension significantly affects patient safety and clinical outcomes during hemodialysis. Despite various pharmacological and nonpharmacological interventions, effective management remains elusive. In this report, we detail a case of intradialytic hypotension in a male patient in his 40s, undergoing hemodialysis with a history of polycystic kidney disease. Eight years ago, the patient underwent bilateral nephrectomy because of a severe cystic infection, after which his systolic blood pressure (BP) persistently remained at 50-70 mm Hg during dialysis sessions. The initial treatment strategy for hypotension included fludrocortisone, midodrine, and prednisolone, leading to a slight temporary increase in BP, which subsequently declined. As the patient's condition deteriorated, the administration of norepinephrine or dopamine became necessary to sustain BP during dialysis. Given the patient's resistance to these treatments, a daily dose of 25 mg of atomoxetine was introduced. Following this treatment, there was a gradual improvement in the patient's vertigo, weakness, and BP. This case illustrates that low-dose atomoxetine can alleviate symptoms and elevate BP in patients experiencing severe intradialytic hypotension during hemodialysis.

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BACKGROUND: Midodrine, an FDA-approved medication for orthostatic hypotension, is also used off-label to manage hypotension in dialysis patients, including those with heart failure. However, in patients with reduced ejection fraction (HFrEF) and/or right heart failure, midodrine is potentially harmful. No known studies examine the safety of midodrine in hospitalised kidney failure patients with HF. METHODS: The TriNetX database was queried for hospitalised kidney failure patients with HFrEF and/or right heart failure who experienced hypotension (SBP < 110 mm Hg or MAP < 70 mm Hg). Excluding those needing critical care or vasopressors, we compared cohorts based on midodrine use, matching for comorbidities. RESULTS: Analysis showed patients on midodrine had a higher 6-month mortality risk ratio (RR 1.53, 95% CI 1.037 to 2.246) and Hazard Ratio (HR 1.54, 95% CI 1.022 to 2.317) compared to those not on midodrine, indicating an association with increased mortality. CONCLUSION: This study illuminates the complexities in treating hospitalised patients with kidney failure and HF. Our findings, drawn from an exploratory analysis, indicate that inpatient midodrine use is associated with increased 6-month mortality. This may reflect deleterious effects from vasoconstriction and/or unmeasured confounders in this vulnerable population. This investigation, utilising TriNetX, was limited by access to deidentified aggregate data, preventing detailed exploration of specifics such as timing, dosage, and indications for midodrine use. Moreover, given its observational nature, cause-effect relationship cannot be established. Our findings indicate an increased mortality associated with midodrine use for hypotension, underscoring the need for further research and consideration of alternative strategies.

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Insuficiencia Cardíaca , Midodrina , Diálisis Renal , Humanos , Midodrina/uso terapéutico , Midodrina/administración & dosificación , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/tratamiento farmacológico , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/terapia , Insuficiencia Cardíaca/complicaciones , Masculino , Femenino , Anciano , Pacientes Internos , Volumen Sistólico/fisiología , Persona de Mediana Edad , Estudios Retrospectivos , Vasoconstrictores/uso terapéutico , Vasoconstrictores/administración & dosificación , Fallo Renal Crónico/terapia , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/mortalidad , Hospitalización/estadística & datos numéricos , Insuficiencia Renal/complicaciones , Insuficiencia Renal/fisiopatología , Insuficiencia Renal/epidemiología , Resultado del Tratamiento , Estados Unidos/epidemiología

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Intradialytic hypotension (IDH) is a severe complication of hemodialysis (HD) with a significant impact on morbidity and mortality. In this study, we used a wearable device for the continuous monitoring of hemodynamic vitals to detect hemodynamic changes during HD and attempted to identify IDH. End-stage kidney disease patients were continuously monitored 15 min before starting the session and until 15 min after completion of the session, measuring heart rate (HR), noninvasive cuffless systolic and diastolic blood pressure (SBP and DBP), stroke volume (SV), cardiac output (CO), and systemic vascular resistance (SVR). Data were analyzed retrospectively and included comparing BP measured by the wearable devices (recorded continuously every 5 s) and the cuff-based devices. A total of 98 dialysis sessions were included in the final analysis, and IDH was identified in 22 sessions (22.5%). Both SBP and DBP were highly correlated (r > 0.62, p < 0.001 for all) between the wearable device and the cuff-based measurements. Based on the continuous monitoring, patients with IDH had earlier and more profound reductions in SBP and DBP during the HD treatment. In addition, nearly all of the advanced vitals differed between groups. Further studies should be conducted in order to fully understand the potential of noninvasive advanced continuous monitoring in the prediction and prevention of IDH events.

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Most end-stage renal disease patients experience a reduction in blood pressure during their hemodialysis session compared to predialysis. Surprisingly, a small subset of patients will experience an unusual physiological response to dialysis that results in a paradoxical increase in blood pressure. We discuss a case that involved an exaggerated elevation in blood pressure, ultimately requiring immediate cessation of dialysis and admission to the intensive care unit for intravenous treatment of a hypertensive emergency. This case serves as a framework to introduce the infrequently discussed concept of intradialytic hypertension. The underlying pathogenesis is poorly understood with multiple theoretical etiologies including activation of the renin-angiotensin-aldosterone system, imbalances in circulating levels of endothelium-derived mediators, clearance of antihypertensive medications, increased cardiac output, and changes in arterial thickness. It is important to be cognizant of this phenomenon as emerging evidence suggests that patients with any elevation in blood pressure during hemodialysis have increased rates of both short-term and long-term mortality.

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Background: Intradialytic hypotension (IDH) is the primary complication of haemodialysis (HD); however, its diverse pathophysiology and inconsistent definitions complicate its prediction. Despite attempts using the heart rate variability (HRV) test for IDH prediction, studies on its usefulness for predicting IDH diagnosed per the nadir 90 criterion are lacking. We aimed to evaluate HRV test efficacy and reproducibility in predicting IDH based on the nadir 90 criterion. Methods: Seventy patients undergoing HD participated in this multicentre prospective observational study. The HRV test was performed during non-HD periods and IDH was monitored during 12 HD sessions. IDH was diagnosed according to the nadir 90 criterion, defined as a decrease in systolic blood pressure of ≤90 mmHg during HD. After monitoring, the HRV test was repeated. An HRV-IDH index was developed using multivariate logistic regression analysis employing HRV test parameters. The predictive power of the HRV-IDH index was analysed using the area under the receiver operating characteristics curve (AUROC). Reproducibility was evaluated using correlation analysis of two HRV tests on the same patient. Results: There were 37 and 33 patients in the IDH and non-IDH groups, respectively. The HRV-IDH index predicted IDH occurrence with AUROCs of 0.776 and 0.803 for patients who had experienced at least one or repeated IDH episodes, respectively. Spearman's correlation coefficient for HRV-IDH indices was 0.859 for the first and second HRV tests. Conclusions: The HRV test holds promise for predicting IDH, particularly for patients with recurring IDH diagnosed based on the nadir 90 criterion.

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Introduction: Calcium channel blockers (CCBs) are common antihypertensive agents among patients receiving hemodialysis (HD). Despite this, the association of CCBs with intradialytic hypotension (IDH), an important adverse outcome that is associated with cardiovascular morbidity and mortality, remains largely unexplored. Methods: Using kinetic modeling sessions data from the Hemodialysis (HEMO) Study, random effects regression models were fit to assess the association of CCB use versus nonuse with IDH (defined as systolic blood pressure [SBP] < 90 mm Hg if pre-HD SBP < 160 mm Hg or < 100 mm Hg if pre-HD SBP ≥160 mm Hg). Models were adjusted for age, biological sex (distinguishing between males and females), race, randomized Kt/V and flux assignments, heart failure, ischemic heart disease, peripheral vascular disease, diabetes mellitus, blood urea nitrogen, ultrafiltration rate, access type, pre-HD SBP, and other antihypertensives. Results: Data were available for 1838 patients and 64,538 sessions. At baseline, 49% of patients were prescribed CCBs. The overall frequency of IDH was 14% with a mean decline from pre- to nadir-SBP of 33 ± 15 mm Hg. CCB use was associated with lower adjusted risk of IDH, compared with no use (incidence rate ratio [IRR]: 0.84; 95% confidence interval [CI]: 0.78-0.89). The association was most pronounced for those in the pre-HD SBP lowest quartile (IRR: 0.77; 95% CI: 0.70-0.85); compared with the highest quartile (IRR: 0.86; 95% CI: 0.77-0.97; P-interaction < 0.001). Conclusion: Among patients receiving HD, CCB use was associated with a lower risk of developing IDH, independent of pre-HD SBP and other antihypertensives use. Mechanistic studies are needed to better understand the effects of CCB and other antihypertensives on peridialytic blood pressure (BP) parameters among patients receiving HD.

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INTRODUCTION: Clinical studies on differences among changes in cerebral and hepatic oxygenation during hemodialysis (HD) in patients with and without intradialytic hypotension (IDH) are limited. We investigated changes in intradialytic cerebral and hepatic oxygenation before systolic blood pressure (SBP) reached the nadir during HD and compared these differences between patients with and without symptomatic IDH. METHODS: We analyzed data from 109 patients with (n = 23) and without (n = 86) symptomatic IDH who were treated with HD. Cerebral and hepatic regional oxygen saturation (rSO2), as a marker of tissue oxygenation and circulation, was monitored during HD using an INVOS 5100c oxygen saturation monitor. Changes in cerebral or hepatic rSO2 when SBP reached the nadir during HD were compared between the groups of patients. RESULTS: The cerebral rSO2 before HD in patients with and without symptomatic IDH was 49.7 ± 11.2% and 51.3 ± 9.1% (p = 0.491). %Changes in cerebral rSO2 did not significantly differ between the two groups from 60 min before the SBP nadir during HD. Hepatic rSO2 before HD in patients with and without symptomatic IDH was 58.5 ± 15.4% and 57.8 ± 15.9% (p = 0.869). The %changes in hepatic rSO2 were significantly lower in patients with symptomatic IDH than in those without throughout the observational period (p < 0.001). We calculated the area under the receiver operating characteristic curve (AUC) and estimated cutoff values for changes in hepatic rSO2 as a symptomatic IDH predictor. The predictive ability at 5 and 40 min before symptomatic IDH onset was excellent, with AUCs and cutoff values of 0.847 and 0.841, and -10.9% and -5.0%, respectively. CONCLUSIONS: Hepatic oxygenation significantly decreased more in patients with symptomatic IDH before its onset, than in those without symptomatic IDH, whereas changes in cerebral oxygenation did not differ. Evaluating changes in hepatic oxygenation during HD might help to predict symptomatic IDH.

Asunto(s)

Hipotensión , Hígado , Oxígeno , Diálisis Renal , Humanos , Hipotensión/etiología , Hipotensión/metabolismo , Masculino , Femenino , Persona de Mediana Edad , Anciano , Hígado/metabolismo , Diálisis Renal/efectos adversos , Oxígeno/metabolismo , Encéfalo/metabolismo , Saturación de Oxígeno , Presión Sanguínea

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Background: Ultrafiltration to target weight during haemodialysis is complicated by intradialytic hypotension-associated adverse events (IHAAEs) in 10-30% of dialysis treatments. IHAAEs are caused by critical reductions in absolute blood volume (ABV), due to the interaction of ultrafiltration, refill and compensatory mechanisms. Non-randomised studies have suggested that ABV-guided treatment, using an indicator dilution technique employing the blood volume monitor on the dialysis machine, could reduce the incidence of IHAAEs. Methods: We performed an open-label randomised controlled trial. Patients were randomly assigned to adjustment of target weight guided by ABV measurements or standard care. The primary outcome was the change in the incidence of IHAAEs from baseline, defined as the percentage of treatment episodes in a 4-week period where the patient had a systolic blood pressure <90 mmHg or symptoms of impending hypotension. ABV measurements were compared with anthropomorphometric estimation and the gold standard using isotope dilution. Results: A total of 56 patients were randomised, of whom 29 were allocated to ABV-guided treatment and 27 to standard care. Overall baseline incidence of IHAAEs was 26.0%. ABV-guided treatment significantly reduced the incidence of IHAAEs compared with standard care, with a mean change from baseline of -9.6% [95% confidence interval (CI) -17.3 to -1.8) versus 2.4% (95% CI -2.3-7.2). The adjusted difference between the groups was 10.5% (95% CI 1.3-19.8; P = .026). ABV measurement had moderate agreement with other methods to estimate blood volume. The sensitivity for the previously suggested threshold of a post-dialysis normalised blood volume of 65 ml/kg was observed to be 74% in this study. Conclusions: ABV-guided volume management significantly reduced IHAAEs compared with standard care. The clinical relevance of the previously suggested threshold of 65 ml/kg cannot be firmly concluded on the basis of our results. If confirmed in a larger trial, this intervention could potentially change dialysis practice and impact patient care in a clinically meaningful way.

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Introduction: due to the catabolic characteristics of hemodialysis (HD), patients should consume foods or supplements during this treatment to meet their energy requirements and maintain a neutral nitrogen balance; however, there are some outcomes in which the effect of intradialytic oral nutrition (ION) is scarcely known. Objectives: this study aims to evaluate the effect of two types of ION (liquid and solid) on Quality of Life (QoL), appetite, and safety in HD patients. Methods: a pilot randomized, crossover clinical trial was performed in 18 patients on chronic HD. One group received ION for 18 HD sessions, after the crossover continued for 18 more sessions in the control group, and vice versa. We recorded QoL, appetite, systolic blood pressure (SBP), and intradialytic hypotension (IH) events. Results: clinical improvement was observed for most QoL components. Regardless of the consistency of supplementation, SBP increased to 4.10 mmHg. Both study groups reported a “very good-to-good” appetite. Conclusion: favorable clinical changes were observed in QoL scores during the study. Five of six IH events were reported for patients in the ION group, and SBP increased within the safe range (≤ 10 mmHg); appetite remained stable in both groups. Therefore, we concluded that this strategy, regardless of implementation consistency, is safe to be used in stable patients.(AU)

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Introducción: debido a las características catabólicas de la hemodiálisis (HD), los pacientes deben consumir alimentos o suplementos durante este tratamiento para cubrir sus requerimientos energéticos y mantener un balance nitrogenado neutro; sin embargo, existen algunos desenlaces en los que el efecto de la nutrición oral intradialítica (NOID) es poco conocido.Objetivo: este estudio tiene como objetivo evaluar el efecto de dos tipos de NOID (líquido y sólido) sobre la calidad de vida, el apetito y la seguridad en pacientes en HD. Métodos: se realizó un estudio piloto en forma de ensayo clínico aleatorizado y cruzado con 18 pacientes en HD crónica. Un grupo recibió NOID durante 18 sesiones de HD, después del cruzamiento continuaron durante 18 sesiones más en el grupo de control, y viceversa. Se registraron la calidad de vida, el apetito, la presión arterial sistólica (PAS) y la hipotensión intradialítica (HI).Resultados: se observó mejoría clínica en la mayoría de los componentes de la calidad de vida. Independientemente de la consistencia de la suplementación, la PAS aumentó hasta 4,10 mmHg. Ambos grupos de estudio informaron de un apetito "muy bueno-bueno". Conclusiones: se observaron cambios clínicos favorables en las puntuaciones de calidad de vida durante el estudio. Cinco de seis eventos de HI se reportaron en pacientes del grupo de NOID y la PAS aumentó dentro del rango seguro (≤ 10 mmHg); el apetito se mantuvo estable en ambos grupos. Por lo tanto, se puede concluir que esta estrategia, independientemente de la consistencia implementada, es segura para ser utilizada en pacientes estables.(AU)

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Humanos , Masculino , Femenino , Diálisis Renal , Seguridad del Paciente , Apetito , Calidad de Vida , Presión Arterial , Hipotensión

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The primary objective of this study is to enhance the prediction accuracy of intradialytic hypotension in patients undergoing hemodialysis. A significant challenge in this context arises from the nature of the data derived from the monitoring devices and exhibits an extreme class imbalance problem. Traditional predictive models often display a bias towards the majority class, compromising the accuracy of minority class predictions. Therefore, we introduce a method called UnderXGBoost. This novel methodology combines the under-sampling, bagging, and XGBoost techniques to balance the dataset and improve predictive accuracy for the minority class. This method is characterized by its straightforward implementation and training efficiency. Empirical validation in a real-world dataset confirms the superior performance of UnderXGBoost compared to existing models in predicting intradialytic hypotension. Furthermore, our approach demonstrates versatility, allowing XGBoost to be substituted with other classifiers and still producing promising results. Sensitivity analysis was performed to assess the model's robustness, reinforce its reliability, and indicate its applicability to a broader range of medical scenarios facing similar challenges of data imbalance. Our model aims to enable medical professionals to provide preemptive treatments more effectively, thereby improving patient care and prognosis. This study contributes a novel and effective solution to a critical issue in medical prediction, thus broadening the application spectrum of predictive modeling in the healthcare domain.

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Hipotensión , Humanos , Reproducibilidad de los Resultados , Hipotensión/etiología , Diálisis Renal/efectos adversos , Diálisis Renal/métodos

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BACKGROUND: Despite the improvements in hemodialysis (HD) technology, 20-30% of sessions are still complicated by hypotension or hypotension-related symptoms. Biofeedback systems have proven to reduce the occurrence of such events, but no conclusive findings can lead to wider adoption of these systems. We conducted this systematic review and meta-analysis of randomized clinical trials to establish whether the use of blood volume tracking systems compared to conventional hemodialysis (C-HD) reduces the occurrence of intradialytic hypotension. METHODS: The PRISMA guidelines were used to carry out this systematic review. Randomized clinical trials that evaluated the incidence of intradialytic hypotension during C-HD and blood volume tracking-HD were searched in the current literature. PROSPERO registration number: CRD42023426328. RESULTS: Ninety-seven randomized clinical trials were retrieved. Nine studies, including 347 participants and 13,274 HD treatments were considered eligible for this systematic review. The results showed that the use of biofeedback systems reduces the risk of intradialytic hypotension (log odds ratio = 0.63, p = 0.03) in hypotension-prone patients (log odds ratio = 0.54, p = 0.04). When analysis was limited to fluid overloaded or hypertensive patients, it did not show the same effect (log odds ratio = 0.79, p = 0.38). No correlation was found in systolic blood pressure drop during dialysis and in post-dialysis blood pressure. CONCLUSIONS: The use of blood volume tracking systems may be effective in reducing the incidence of intradialytic hypotension and allowing for easier attainment of the patients' ideal dry body weight. New studies to examine the long-term effects of the use of blood volume tracking systems on real hard endpoints are needed.

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Biorretroalimentación Psicológica , Presión Sanguínea , Volumen Sanguíneo , Hipotensión , Ensayos Clínicos Controlados Aleatorios como Asunto , Diálisis Renal , Humanos , Diálisis Renal/efectos adversos , Hipotensión/prevención & control , Hipotensión/etiología , Biorretroalimentación Psicológica/métodos , Resultado del Tratamiento , Factores de Riesgo , Determinación del Volumen Sanguíneo/métodos

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Background: Intradialytic hypotension (IDH) is a critical complication related to worse outcomes in patients undergoing maintenance hemodialysis. Herein, we addressed the impact of IDH on mortality and other outcomes in patients with severe acute kidney injury (AKI) requiring intermittent hemodialysis. Methods: We retrospectively reviewed 1,009 patients who underwent intermittent hemodialysis due to severe AKI. IDH was defined as either dialysis discontinuation due to hemodynamic instability or a decrease in systolic blood pressure (BP) of ≥30 mmHg, with or without a nadir systolic BP of <90 mmHg during the first session. The primary outcome was all-cause mortality, and transfer to the intensive care unit (ICU) due to unstable status was additionally analyzed. Hazard ratios (HRs) of outcomes were calculated using a Cox regression model after adjusting for multiple variables. Risk factors for IDH were evaluated using a logistic regression model. Results: IDH occurred in 449 patients (44.5%) during the first hemodialysis session. Patients with IDH had a higher mortality rate than those without IDH (40% vs. 23%; HR, 1.30; 95% confidence interval [CI], 1.02-1.65). The rate of ICU transfer was higher in patients experiencing IDH than in those without IDH (17% vs. 11%; HR, 1.43; 95% CI, 1.02-2.02). Factors such as old age, high BP and pulse rate, active malignancy, cirrhosis, and hypoalbuminemia were associated with an increased risk of IDH episodes. Conclusion: The occurrence of IDH is associated with worse outcomes in patients with AKI requiring intermittent hemodialysis. Therefore, careful monitoring and early intervention of IDH may be necessary in this patient subset.

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Rationale & Objective: Intradialytic hypotension (IDH) is associated with mortality in adults with kidney failure requiring hemodialysis (HD); however, large-scale pediatric studies are lacking. Moreover, there is no evidence-based consensus definition of IDH in pediatric literature. We aimed to examine the association of commonly used definitions of IDH with mortality in adolescents and young adults. Study Design: This was a retrospective observational cohort study. Setting & Participants: In total, 1,199 adolescents and young adults (N = 320, aged 10-18 years and N = 879, aged 19-21 years) who initiated HD in a large dialysis organization were included. Exposures: This study used different definitions of IDH. Outcome: The study outcome was 2-year all-cause mortality. Analytical Approach: Several definitions of IDH were selected a priori based on a literature review. Patients were classified as having IDH if it was present in at least 30% of HD treatments during the first 90 days after dialysis initiation. Cox proportional hazards regression was used to test whether IDH associated with 2-year all-cause mortality. Results: Over a 2-year follow-up period, 54 (4.5%) patients died. Dependent on its definition, IDH was present in 2.9%-61.1% of patients. After the multivariable adjustment for sociodemographic and clinical characteristics, we found no association of IDH with mortality. Results were consistent across subgroups stratified by age (aged <18 and 19-21 years) and predialysis systolic blood pressure (<120, 120-150, and >150 mm Hg). We also examined IDH as occurring in <5%, 5%-29%, 30%-50%, and >50% of baseline treatments, and did not find a dose-response association with mortality (P > 0.05). Limitations: Owing to low event rates, our current sample size may have been too small to detect a difference in mortality. Conclusions: Our study found that IDH was not associated with mortality in adolescents and young adults.

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Intradialytic hypotension (IDH), or hypotension experienced during dialysis, is common among children and young adults with kidney failure requiring hemodialysis. We examined the association of commonly used definitions of IDH with death in adolescents and young adults with kidney failure receiving hemodialysis. Intradialytic hypotension was present in 2.9%-61.1% of patients, depending on the definition, and over a 2-year follow-up period, 4.5% of the patients died. We found no association of IDH with mortality.

RESUMEN

Background: Intradialytic hypotension (IDH) is a common hemodialysis complication causing adverse outcomes. Despite the well-documented associations of ambient temperatures with fluid removal and pre-dialysis blood pressure (BP), the relationship between ambient temperature and IDH has not been adequately studied. Methods: We conducted a cohort study at a tertiary hospital in southern Taiwan between 1 January 2016 and 31 October 2021. The 24-h pre-hemodialysis mean ambient temperature was determined using hourly readings from the weather station closest to each patient's residence. IDH was defined using Fall40 [systolic BP (SBP) drop of ≥40 mmHg] or Nadir90/100 (SBP <100 if pre-dialysis SBP was ≥160, or SBP <90 mmHg). Multivariate logistic regression with generalizing estimating equations and mediation analysis were utilized. Results: The study examined 110 400 hemodialysis sessions from 182 patients, finding an IDH prevalence of 11.8% and 10.4% as per the Fall40 and Nadir90/100 criteria, respectively. It revealed a reverse J-shaped relationship between ambient temperature and IDH, with a turning point around 27°C. For temperatures under 27°C, a 4°C drop significantly increased the odds ratio of IDH to 1.292 [95% confidence interval (CI) 1.228 to 1.358] and 1.207 (95% CI 1.149 to 1.268) under the Fall40 and Nadir90/100 definitions, respectively. Lower ambient temperatures correlated with higher ultrafiltration, accounting for about 23% of the increased IDH risk. Stratified seasonal analysis indicated that this relationship was consistent in spring, autumn and winter. Conclusion: Lower ambient temperature is significantly associated with an increased risk of IDH below the threshold of 27°C, irrespective of the IDH definition. This study provides further insight into environmental risk factors for IDH in patients undergoing hemodialysis.