Document Detail

Association of intradialytic hypotension and convective volume in hemodiafiltration: results from a retrospective cohort study.
Jump to Full Text
MedLine Citation:
PMID:  22963170     Owner:  NLM     Status:  Publisher    
Abstract/OtherAbstract:
ABSTRACT: BACKGROUND: Hemodiafiltration (HDF), as a convective blood purification technique, has been associated with favorable outcomes improved phosphate control, removal of middle-molecules such as Beta2-microglobulin and the occurrence of intradialytic hypotension (IDH) as compared to diffusive techniques. The aim of this retrospective cohort study in dialysis patients receiving HDF in one urban dialysis facility in Mexico City was to investigate the occurrence of IDH during HDF treatments with varying convective volume prescriptions. METHODS: Subjects were stratified into equal groups of percentiles of convective volume prescription: Group 1 of 0 to 7.53 liters, group 2 of 7.54 to 14.8 liters, group 3 of 14.9 to 16.96 liters, group 4 of 16.97 to 18.9 liters, group 5 of 21 to 19.9 liters and group 6 of 21.1 to 30 liters. Logistic Regression with and without adjustment for confounding factors was used to evaluate factors associated with the occurrence of IDH. RESULTS: 2276 treatments of 154 patients were analyzed. IDH occurred during 239 HDF treatments (10.5% of all treatments). Group 1 showed 31 treatments (8.2%) with IDH whereas group 6 showed IDH in only 15 sessions (4% of all treatments). Odds Ratio of IDH for Group 6 was 0.47 (95% CI 0.25 to 0.88) as compared to Group 1 after adjustment. CONCLUSIONS: In summary the data of this retrospective cohort study shows an inverse correlation between the occurrence of IDH and convective volume prescription. Further research in prospective settings is needed to confirm these findings.
Authors:
Franklin G Mora-Bravo; Guadalupe De-La-Cruz; Sonia Rivera; Alfonso Mariscal-Ramírez; Jochen G Raimann; Héctor Pérez-Grovas
Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2012-9-10
Journal Detail:
Title:  BMC nephrology     Volume:  13     ISSN:  1471-2369     ISO Abbreviation:  BMC Nephrol     Publication Date:  2012 Sep 
Date Detail:
Created Date:  2012-9-11     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  100967793     Medline TA:  BMC Nephrol     Country:  -    
Other Details:
Languages:  ENG     Pagination:  106     Citation Subset:  -    
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms
Descriptor/Qualifier:

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): BMC Nephrol
Journal ID (iso-abbrev): BMC Nephrol
ISSN: 1471-2369
Publisher: BioMed Central
Article Information
Download PDF
Copyright ©2012 Mora-Bravo et al.; licensee BioMed Central Ltd.
open-access:
Received Day: 9 Month: 2 Year: 2012
Accepted Day: 22 Month: 8 Year: 2012
collection publication date: Year: 2012
Electronic publication date: Day: 10 Month: 9 Year: 2012
Volume: 13First Page: 106 Last Page: 106
PubMed Id: 22963170
ID: 3575237
Publisher Id: 1471-2369-13-106
DOI: 10.1186/1471-2369-13-106

Association of intradialytic hypotension and convective volume in hemodiafiltration: results from a retrospective cohort study
Franklin G Mora-Bravo1 Email: franklin.mora.bravo@gmail.com
Guadalupe De-La-Cruz2 Email: gpe.delacruz.2@gmail.com
Sonia Rivera2 Email: cati.rivera.gonzalez@hotmail.com
Alfonso Mariscal Ramírez2 Email: mariscalmd@yahoo.com.mx
Jochen G Raimann3 Email: JRaimann@rriny.com
Héctor Pérez-Grovas2 Email: hpgrovas@gmail.com
1Servicio de Nefrología, Hospital José Carrasco Arteaga, Cuenca, Ecuador
2Servicio de Nefrología, Instituto Nacional De Cardiología Ignacio Chávez, Coyacan, DF, México
3Renal Research Institute, New York, USA

Background

Despite continuous progress of dialysis technologies intradialytic hypotension (IDH) remains a major problem in the treatment of patients suffering from chronic kidney disease stage 5D [1-3].

Rapid removal of intravascular volume by ultrafiltration results in hemodynamic instability if it exceeds the compensatory vascular refilling from the interstitial volume [4,5]. The critical blood volume at which symptomatic hypotension occurs varies from patient to patient [4,6,7] and is influenced by myocardial contractility, heart rate, and peripheral vascular resistances [8]. It may also be noted that the vascular response to reduction in blood volume is additionally strongly determined by changes in body temperature during the treatment. Factors such as the mass transfer of sodium and calcium have also been reported to associate to hemodynamic stability.

Regular use of high-efficiency on line HDF is associated with reduced morbidity (better blood pressure control, improved lipid profile, improved anemia correction and phosphate control, improved removal of beta2-microglobulin, reduction of amyloidosis and hospitalization) [9-11]. A reduction of inflammatory markers during has also been reported recently [12]. More recently, several cohort studies have shown that high-efficiency on line HDF is associated with a reduced risk of mortality [9,13]. It has also been suggested that convective methods of blood purification may improve patient outcomes, which may include a reduction of intradialytic hypotensive episodes [14-17].

Hemodiafiltration can be categorized according to the used convective volume replacement during the course of the treatment. Low-efficiency HDF includes replacements of 5 to 14.9 liters, whereas high-efficiency HDF includes replacement of 15 to 24.9 liters. A recently published analysis of the Dialysis Outcomes and Practice Patterns Study (DOPPS) reported an association between survival and the amount of convective volume [13].

To the best of the authors’ knowledge the relation of the convective volume during HDF and intradialytic hypotension has not been studied to date. This retrospective cohort study aimed to evaluate the relation between the occurrence of intradialytic hypotension and the use of different amounts of convection volume during HDF.


Methods
Patients selection

The database contains records of 167 patients and 6137 treatments. We selected cases for analysis from that group.

Subjects received thrice-weekly HDF sessions for a minimum duration of 3 hours during the period from 07/01/2005 and 07/16/2006 in the dialysis unit of the Instituto Nacional De Cardiología Ignacio Chavez in Mexico City, were included in this analysis. Patients were stratified into 6 equal groups of convection volume prescription (based on percentiles of convective volume in the entire dataset), and for a confirmatory analysis into 7 groups, where the reference group was not receiving HDF with convective volume. This retrospective study was approved by the Institutional Review Board of Instituto Nacional de Cardiología Ignacio Chávez (Reference #: IMIN-2010-TL-27).

Treatment characteristics

Extracorporeal blood Flow (Qb) was chosen according to the unit's policy and was aimed keep the arterial pressure between −200 to −250 mmHg, but with a prescription limit of 500 ml/min. Patients received systemic anticoagulation with heparin-sodium 2.000 units at the beginning of treatment and 1000 units per hour. In addition dialysis filters and -lines were also heparinized with 1000 units of sodium-heparin in a 1 liter of 0.9% saline solution.

Postdilutional HDF sessions were delivered by Fresenius 4008 H dialysis machines (Fresenius Medical Care Germany, Bad Homburg, Germany). The machines are equipped with a pre pump measuring system for dynamic arterial line pressure, blood temperature monitor (BTM) for measurements of access recirculation, an on-line clearance monitor (OCM) and the blood Volume Monitor (BVM). Urea Kinetic Volume in Litters was determined by Watson Formula [18].

High-Flux polysulfone membrane dialyzers F-60 and F-80 were used (Fresenius Medical Care North America, Walnut Creek, CA, USA). Dialysis filters and blood lines were re-used up to 10 ± 4 times and disinfected by formaldehyde after each treatment. Dialysate/infusate compositions were sodium 135 mEq/L, potassium 3 mEq/L, calcium 3 mEq/L, bicarbonate 30 mEq/L and glucose 200 mg/dL. Ultra pure bicarbonate dialysate was delivered. The studied patients had no dietary fluid or salt restrictions, but were recommended high protein and calorie intake. Prescription of sufficient convective volume was made aiming for a trans-membranous pressure of 200 mmHg.

IDH was defined as per the K/DOQI guidelines [19], defined as a decrease in systolic BP of 20 mmHg or a decrease in mean arterial pressure (MAP) by 10 mmHg associated with clinical events, such as headache, nausea, vomiting and cramps, and the need for nursing interventions as per standard of care (injection of a 50 mL bolus of hyperosmolar glucose, placing the patient in Trendelenburg position and temporary cease of ultrafiltration).

UF rate algorithm

The relative blood volume (RBV) was measured on line with the Blood Volume Monitor (BVM). At the start of hemodialysis the RBV was equal to 100%. We program the critical limit for stopping ultrafiltration, when RBV is less than 78%. We program the ultrafiltration maximum rate with a value of 3000 mL/hour.

Statistical analysis

Data was tested for normal distribution by Shapiro-Wilk test. Parametric data was reported as mean standard deviation and non-parametric as median [Inter quartile Range (IQR) from 25th to 75th percentile]. Differences between groups were tested by means of Analysis of Variance (ANOVA) and Post-Hoc Bonferroni-Dunnett Test. Logistic Regression analysis with only groups of convective volume included was employed to test the hypothesis that convective volume associates to the occurrence of IDH. Additional adjustment of the model by relevant clinical parameters [pre HDF systolic blood pressure (SBP), albumin, ultrafiltration rate, pre HDF body temperature, post HDF weight] was employed to exclude confounding of the results.


Results
Study cohort

Records of 2276 post-dilution HDF session of 154 patients were included in this retrospective cohort study. Patients were categorized in six equal groups according to percentiles of convective volume prescription data: Group 1: 0 to 7.53 liters, Group 2: 7.54 to 14.8 liters; Group 3: 14.9 to16.96 liters; Group 4: 116.97 to 18.9 liters; Group 5: 19.1 to 21 liters, and Group 6: 21.1 to 30 liters. All patients were of Hispanic ethnicity, the rest of the demographics of the studied cohort are shown in Table 1. None of the subjects had an active prescription of antihypertensive medication.

Treatment characteristics

HD parameters are shown in Table 2. Treatment time, conductivity, dialysate temperature, arterial and venous line pressure, sodium prescription was similar in all studied groups (Table 2). Small significant differences between the groups were found for processed blood volume, total spent dialysate, blood and dialysate flow (Table 3). The achieved ionic Kt/V in the studied treatments showed significant differences between the groups, with higher values associating to higher convection volumes. Information on interdialytic weight gain expressed as percentage of dry weight is in the Table 1.

Intradialytic hypotension

During the study period, IDH occurred in 239 study treatments (10.5% of all studied HD sessions; Table 4). Logistic regression was employed to analyze the association of convective volume to the occurrence of intradialytic symptoms. The first model included only groups of convective volume (Table 5a)and showed a significantly decreased risk of IDH as compared to the reference group. After inclusion of relevant clinical parameters this relation remained significant (Table 5b). For the confirmatory analysis all subjects were stratified in 7 groups of convective volume, where the reference group did receive HDF with convective volume. The results were similar to the primary analysis and showed that Group 7 had a lower risk of IDH as compared to group 1 and 2 (Table 6 and Figure 1). Ultrafiltration rate register each 15 minutes is in the Table 7.


Discussion
Statement of principal findings

The present study shows that the group with the highest convective volume used for HDF has the lowest occurrence of IDH. This association was independent of relevant clinical factors such as pre HDF SBP, albumin, ultrafiltration rate, pre HDF body temperature and post HDF weight. A confirmatory analysis where patients receiving treatment with no convective volume were used as the reference group showed results consistent with the primary analysis. A non-significant trend of increasing risk of IDH with decreasing convective volume may be interpreted in Table 5a and b.

Strengths

It may be outlined that potential confounders such as dialysate temperature, dialysate sodium and calcium did not significantly differ between the groups, which may be considered a strength of the present analysis. It is also important to note that potential confounders of the analysis such as ultrafiltration rate and albumin, which are main determinants of vascular refilling in response to interdialytic fluid removal, were included in an adjusted Logistic Regression model and did not alter the results. Particularly the inclusion of ultrafiltration rate in the analysis reduces the possible confounding influence caused by the significant differences found in interdialytic weight gain (Table 1). Inclusion of pre HDF SBP excludes the possibility that patients with higher SBP may have larger decreases (and thus higher likelihood of experiencing IDH) or those with lower SBP may have lower cardiac function and thus more likely to experience IDH. An additional strength of this analysis is the sample size which is considerable large with 2276 HDF treatments in 154 included subjects.

Weaknesses of the study

Limitations of the current study are the retrospective nature of the analysis it is based on a re analysis of available data, and the considerably homogenous study population recruited in an urban dialysis facility in Mexico City. This trial has no information about water transfer from the vascular into the interstitial space, effective circulating volume, accurate information on mass transfer of solutes possibly relevant for hemodynamic stability (in particular sodium or calcium) and measurement of inflammatory markers serum interleukins. Additional confounding may have occurred due to differences in change of body core temperature which may alter the vascular response to removal of intravascular volume. No measurements of body core temperature were performed. Peripheral pre and post temperature was measured by blood thermal monitor and did not show significant differences (Table 1).

Strengths and weaknesses in relation to other studies

Very few of the studies comparing HD and HDF have taken into account that these techniques differ in the operative settings of several variables potentially affecting the hemodynamic response to the procedure, namely, the rate of convective transport, the efficiency of small and large solute removal, the buffer used in the dialysate, sodium balance, treatment time and the type of membrane. A recently reported study in 34 patients reported that replacement volumes greater than 16 liters HDF not have a protective effect of hypotension [20]. Is this trial Pinney, et al. used a replacement volume from 16 to 21 liters. In general the results are consistent with our results because the 16-liter volume used in our work gives an OR of 1.059 (0.629 to 1.784). As can be seen in Figure 1, the convective volumes greater than 21 liters are those which decrease the risk of IDH. Several studies, carried out subsequently, reinforced the belief that procedures based on convective transport are superior to those based on diffusive transport in protecting the stability of blood pressure and heart rate [2-4,6,7].

Possible mechanisms

Strong support in favor of HDF came from a series of hemodynamic studies showing that, for equal amounts of fluid removed, HDF elicited an appropriate increase in peripheral vascular resistance, whereas standard HD failed to do so [8]. Shaldon et al. hypothesized that the dialysate itself must be “the” vascular stabilizer with a rationale interleukin removal as the framework of the hypothesis [21]. Interleukins increase capillary permeability, resulting in water capillary leakage from the vascular into the interstitial space. This hypothesis has not yet specifically been investigated for HDF treatments, but recently a reduction of inflammatory markers in patients receiving HDF treatments has been reported [12]. To what extent this is related and consistent with the hypothesis of Shaldon et al. requires further research. An additional aspect which also requires more research is the mass transfer of sodium and calcium. Although a positive sodium transfer will raise the osmolality and quite likely result in increased interdialytic weight gains and blood pressure, a negative sequelae which should be avoided in patients suffering from renal impairment. However, it may not be excluded that mast transfer of sodium confounded our results by changing serum osmolality and affecting hemodynamic stability. The same accounts for calcium mass transfer, which is also of hemodynamic importance for patients receiving renal replacement therapy according to work by van der Sande et al. [22]. The techniques that are based on convective transport also entail a significant cooling of the blood flowing in the extracorporeal circuit [23-27] which may also affect hemodynamic stability. This is because in an isothermal treatment, difference between arterial line temperature (from the patient) and the venous line temperature (from the machine) is greater than 0.5 degrees Celsius for the arterial line (measured by Blood Thermal Monitor).


Conclusions

At this point no definitive statement can be given and additional research is needed to confirm the findings of this research in a prospective setting. However, in summary the data of this retrospective cohort study shows an inverse correlation between the occurrence of intradialytic hypotension and convective volume prescription. This study is limited by its retrospective design and, although quite promising initial results in terms of hemodynamic stability are shown, much additional research is needed.


Competing interests

All authors have no competing interests.


Authors’ contributions

FMB participated in the design of the study, acquired the data, managed the data analysis and interpretation of the data, and drafted the manuscript. JGR substantially contributed to the interpretation of the data and critically revised the manuscript. GDC participated in the design of the study, acquired the data, and managed the data. SR assisted in the study design, performed the statistical analysis, contributed to the interpretation of the data, and critically revised the manuscript. AM participated in the study design and data interpretation, and critically revised the manuscript. HPG conceived of the study, participated in the study design and critically revised the manuscript. All authors read and approved the final manuscript.


Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2369/13/106/prepub


Acknowledgements

The data reported here was collected by the Instituto Nacional de Cardiología Ignacio Chávez “INCICH”. The contribution of all registry participants, in particular of nephrologists and other healthcare professionals, who collected the data and conducted the quality control, is acknowledged. Interpretations of this data are the sole responsibility of the authors and do not represent an official policy or interpretation of INCICH Registry.


References
Daugirdas JT,Preventing and managing hypotensionSemin DialYear: 19947276283
Locatelli F,Andrulli S,Di Filippo S,et al. Effect of on-line conductivity plasma ultrafiltrate kinetic modeling on cardiovascular stability of hemodialysis patientsKidney IntYear: 199853105210609551417
Donauer J,Schweiger C,Rumberger B,et al. Reduction of hypotensive side effects during online-haemodiafiltration and low temperature haemodialysisNephrol Dial TransplantYear: 2003181616162210.1093/ndt/gfg20612897103
Zucchelli P,Santoro A,Dry weight in hemodialysis: Volemic controlSemin NephrolYear: 20012128629010.1053/snep.2001.2167211320496
Flythe J,Kimmel S,Brunelli S,Rapid fluid removal during dialysis is associated with cardiovascular morbidity and mortalityKidney IntYear: 20117925025710.1038/ki.2010.38320927040
Bogaard HJ,de Vries JPPM,de Vries PMJM,Assessment of refill and hypovolaemia by continuous surveillance of blood volume and extracellular fluid volumeNephrol Dial TransplantYear: 19949128312877816290
Steuer R,Leypoldt J,Cheung A,et al. Hematocrit as an indicator of blood volume and a predictor of intradialytic morbid eventsASAIO JYear: 199440M691M69610.1097/00002480-199407000-000878555603
Daugirdas JT,Dialysis hypotension: A hemodynamic analysisKidney IntYear: 19913923324610.1038/ki.1991.282002637
Canaud B,Effect of online hemodiafiltration on morbidity and mortality of chronic kidney disease patientsContrib NephrolYear: 200715821622417684361
Hornberger JC,Chernew M,Petersen J,Garber AM,A multivariate analysis of mortality and hospital admissions with high flux dialysisJ Am Soc NephrolYear: 19923122712371477318
Hakim RM,Held PJ,Stannard DC,Wolfe RA,Port FK,Daugirdas JT,Agodoa L,Effect of the dialysis membrane on mortality of chronic haemodialysis patientsKidney IntYear: 19965056657010.1038/ki.1996.3508840287
City Gil C,Lucas C,Possante C,Jorge C,Gomes F,Candeias M,Lages H,Arranhado E,Ferreira A,On-line haemodiafiltration decreases serum TNFalpha levels in haemodialysis patientsNephrol Dial TransplantYear: 200318244744810.1093/ndt/18.2.44712543911
Canaud B,Bragg-Gresham JL,Marshall MR,Desmeules S,Gillespie BW,Depner T,Klassen P,Port FK,Mortality risk for patients receiving hemodiafiltration versus hemodialysis: European results from the DOPPSKidney IntYear: 2006692087209310.1038/sj.ki.500044716641921
Altieri P,Sorba GB,Bolasco PG,Bostrom M,Asproni E,Ferrara R,Bolasco F,Cossu M,Cadinu F,Cabiddu GF,Casu D,Ganadu M,Passaghe P,Pinna M,On line predilution hemofiltration versus ultrapure high-flux hemodialysis: A multicenter prospective study in 23 patientsBlood PurifYear: 19971516918110.1159/0001703289262843
Altieri P,Sorba GB,Bolasco PG,Asproni E,Ledevo I,Cossu M,Ferrara R,Ganadu M,Cadinu M,Serra G,Cabiddu G,Sau G,Casu D,Passaghe M,Bolasco F,Pistis R,Ghisu T,Predilution haemofiltration: The Second Sardinian Multicentre Study—Comparison between haemofiltration and haemodialysis during identical Kt/V and session times in a long-term cross-over studyNephrol Dial TransplantYear: 2001161207121310.1093/ndt/16.6.120711390722
Locatelli F,Altieri P,Andrulli S,Bolasco P,Sau G,Pedrini L,Basile C,David S,Feriani M,Montagna G,Raffaele Di Iorio B,Memoli B,Cravero R,Battaglia G,Zoccali C,Hemofiltration and Hemodiafiltration Reduce Intradialytic Hypotension in ESRDJ Am Soc NephrolYear: 2010211798180710.1681/ASN.201003028020813866
Vilar E,Fry AC,Wellsted D,Tattersall JE,Greenwood RN,Farrington K,Long-term outcomes in online hemodiafiltration and high-flux hemodialysis: a comparative analysisClin J Am Soc NephrolYear: 2009121944195319820129
Watson PE,Watson ID,Batt RD,Total body water volumes for adult males and females estimated from simple anthropometric measurementsAm J Clin NutrYear: 19803312739 Jan. 6986753
National Kidney FoundationK/DOQI Clinical Practice Guidelines for Cardiovascular Disease in Dialysis PatientsAm J Kidney DisYear: 200545suppl 3S1S154
Pinney JH,Oates T,Davenport A,Haemodiafiltration does not reduce the frequency of intradialytic hypotensive episodes when compared to cooled highflux haemodialysisNephron Clin PractYear: 2011119213814410.1159/000324428
Henderson LW,Koch KM,Dinarello CA,Shaldon S,Hemodialysis hypotension: the interleukin hypothesisBlood PurifYear: 1983113810.1159/000166438
van der Sande FM,Cheriex EC,van Kuijk WH,Leunissen KM,Effect of dialysate calcium concentrations on intradialytic blood pressure course in cardiac-compromised patientsAm J Kidney DisYear: 19983211253 Jul. 10.1053/ajkd.1998.v32.pm96694339669433
Locatelli F,Marcelli D,Conte F,Limido A,Malberti F,Spotti D,Registro Lombardo Dialisi e TrapiantoComparison of mortality in ESRD patients on convective and diffusive extracorporeal treatmentsKidney IntYear: 19995528629310.1046/j.1523-1755.1999.00236.x9893138
Leypoldt JK,Cheung AK,Carroll CE,Stannard DC,Pereira BJ,Agodoa LY,Port FK,Effect of dialysis membranes and middle molecule removal on chronic hemodialysis patient survivalAm J Kidney DisYear: 19993334935510.1016/S0272-6386(99)70311-210023649
Locatelli F,Martin-Malo A,Hannedouche T,Loureiro A,Papadimitriou M,Wizemann V,Jacobson SH,Czekalski S,Ronco C,Vanholder R,Effect of membrane permeability on survival of hemodialysis patientsJ Am Soc NephrolYear: 20092064565410.1681/ASN.200806059019092122
Locatelli F,Mastrangelo F,Redaelli B,Ronco C,Marcelli D,La Greca G,Orlandini G,Italian Cooperative Dialysis Group: Effect of different membranes and dialysis technologies on patient treatment tolerance and nutritional parametersKidney IntYear: 1996501293130210.1038/ki.1996.4418887291
Mora-Bravo F,Mariscal A,Herrera-Felix J,Magaña S,De-La-Cruz G,Flores N,Rosales L,Franco M,Pérez-Grovas H,Arterial line pressure control enhanced extracorporeal blood flow prescription in hemodialysis patientsBMC NephrolYear: 200891510.1186/1471-2369-9-1519025625

Figures

[Figure ID: F1]
Figure 1  

Forest plot diagram to represent odds ratio of hemodiafiltration volume for Intradialytic Hypotension. The groups of convective volume were defined as follows: Group 1: 0 to 0.2 liters. Group 2: 0.3 to 7.53 liters, Group 3: 7.54 to 14.8 liters; Group 4: 14.9 to 16.96 liters; Group 5: 16.97 to 18.9 liters; Group 6: 19.1 to 21 liters, and Group 7: 21.1 to 30 liters.



Tables
[TableWrap ID: T1] Table 1 

Patients demographics


Parameter Sixtiles of convective volume prescription
Anova Dunnett Post Hoc Test
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 P<0.05 P>0.05
Patients [count]
23
25
22
29
27
28
 
Treatments [count]
379
382
377
382
380
376
Age [Years]
43.4 ± 15
44.5 ± 16
48.2 ± 11
43.2 ± 16
46.3 ± 14
48.9 ± 12
NS
None
1 vs. 2-6
Gender Female [count [%]]
11 [47.8%]
12 [48%]
10 [45.5%]
14 [48%]
12 [44%]
11 [39%]
NS
Chi Square Test
Pre HDF Weight [Kg]
63.8 ±13.0
61.6 ±12.5
61.4 ±13.0
61.0 ±12.8
60.5 ±12.7
60.8 ±15.3
NS
None
1 vs. 2-6
Post HDF Weight [Kg]
61.4 ± 13.0
58.5 ± 12.2
58.7 ± 13.1
58.2 ± 12.8
57.9 ± 12.6
59.4 ± 13.0
NS
None
1 vs. 2-6
Temperature pre HDF [Celsius]
36.72 ± 0.36
36.55 ± 0.45
36.56 ± 0.42
36.54 ± 0.41
36.55 ± 0.43
36.55 ± 0.42
NS
None
1 vs. 2-6
Temperature post HDF [Celsius]
36.98 ± 0.39
36.81 ± 0.50
36.84 ± 0.48
36.85 ± 0.39
36.85 ± 0.39
36.82 ± 0.38
NS
None
1 vs. 2-6
Delta Temperature [Celsius]
0.27 ± 0.29
0.27 ± 0.38
0.28 ± 0.37
0.30 ± 0.29
0.28 ± 0.27
0.28 ± 0.28
NS
None
1 vs. 2-6
Interdialytic Weight Gain [% post HDF target weight]
4.2 ± 2.0
5.2 ± 2.1
4.8 ± 2.5
5.0 ± 2.3
4.6 ± 2.2
4.0 ± 2.1
<0.0001
1 vs. 2-4
1 vs. 5-6
Pre HDF Systolic Blood Pressure [mmHg]
136 ± 29
147 ± 28
143 ± 28
139 ± 27
137 ± 26
136 ± 26
<0.0001
1 vs. 2-3
1 vs. 4-6
Pre HDF Diastolic Blood Pressure [mmHg]
70 ± 20
77 ± 21
75 ± 22
75 ± 23
71 ± 22
69 ± 21
<0.0001
1 vs. 2-4
1 vs. 5,6
Pre HDF MAP Blood Pressure [mmHg]
93 ± 23
102 ± 23
99 ± 23
98 ± 23
95 ± 22
93 ± 22
<0.0001
1 vs. 2-4
1 vs5,6
Pre HDF Pulse Rate [bpm] 94 ± 15 93 ± 16 94 ± 18 95 ± 15 94 ± 16 94 ± 16 NS None 1 vs.2-6

Group 1: 0 to 7.53 liters, Group 2: 7.54 to 14.8 liters; Group 3: 14.9 to 16.96 liters; Group 4: 16.97 to 18.9 liters; Group 5: 19.1 to 21 liters, and Group 6: 21.1 to 30 liters. Not significant (NS).


[TableWrap ID: T2] Table 2 

Characteristics of hemodiafiltration (HDF) treatments


Parameter Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Anova P<0.05 P>0.05
Effective Dialysis Time [min]
217 ± 14
205 ± 17
210 ± 18
214 ± 17
217 ± 17
219 ± 16
NS
None
1 vs. 2-6
Total Blood Volume [liters]*
88.6 ± 14.5
74.8 ± 15.8
82.5 ± 13.4
88.7 ± 12.6
92.2 ± 11.4
97.2 ± 10.5
<0.0001
1 vs.5,6.
1 vs.2-4
Extracorporeal Blood Flow [mL/min]
406 ± 63
361 ± 71
389 ± 62
412 ± 58
423 ± 55
442 ± 52
<0.0001
1 vs.5,6.
1 vs.2-4
Dialysate Flow [ml/min]
522 ± 41
613 ± 36
632 ± 37
643 ± 45
672 ± 47
703 ± 34
<0.0001
1 vs.2-6
None
Ultrafiltration [litters]
2.62 ± 0.85
3.05 ± 1.03
2.89 ± 1.12
2.97 ± 1.14
2.67 ± 1.09
2.41 ± 1.04
<0.0001
1 vs.2-4
1 vs.5,6
Conductivity [mS/cm3]
14.0 ± 0.2
14.0 ± 0.1
14.1 ± 0.1
14.1 ± 0.1
14.1 ± 0.1
14.1 ± 0.1
NS
None
1 vs.2-6
Dialysate temperature [Celsius]
35.74 ± 0.35
35.64 ± 0.37
35.64 ± 0.38
35.62 ± 0.35
35.64 ± 0.30
35.68 ± 0.32
NS
None
1 vs.2-6
Arterial Line Pressure [mmHg]
−201 ± 35
−205 ± 34
−211 ± 29
−218 ± 26
−217 ± 27
−215 ± 28
NS
None
1 vs.2-6
Venous Line Pressure [mmHg]
205 ± 53
176 ± 59
176 ± 46
180 ± 41
186 ± 40
198 ± 44
NS
None
1 vs.2-6
Dialysate sodium prescription [mEq/L] 138 ± 0.7 138 ± 0.8 138 ± 0.6 138 ± 0.6 138 ± 0.6 138 ± 0.4 NS None 1 vs.2-6

* Total Blood Volume = Qb*Dialysis Time. Group 1: 0 to 7.53 liters, Group 2: 7.54 to 14.8 liters; Group 3: 14.9 to 16.96 liters; Group 4: 16.97 to 18.9 liters; Group 5: 19.1 to 21 liters, and Group 6: 21.1 to 30 liters. Not significant (NS).


[TableWrap ID: T3] Table 3 

Clinical parameters


Parameter Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Anova P<0.05 P>0.05
Recirculation fraction [%]
13.0 ± 6.7
14.4 ± 9.0
12.1 ± 6.6
12.5 ± 8.7
13.8 ± 8.5
13.1 ± 7.4
NS
None
1 vs.2-6
Ionic Kt/V
1.37 ± 0.33
1.27 ± 0.34
1.39 ± 0.36
1.44 ± 0.41
1.60 ± 0.39
1.66 ± 0.38
<0.0001
1 vs.5,6
1 vs.2-4
Urea Kinetic Volume [Liters]
31.3 ± 5.5
31.0 ± 6.8
33.2 ± 7.3
33.0 ± 7.0
31.7 ± 7.3
33.7 ± 7.9
NS
None
1 vs.2-6
Clearance [ml/min]
183 ± 36
172 ± 50
196 ± 36
209 ± 32
219 ± 31
235 ± 31
<0.0001
1 vs.3-6
1 vs.2
Minimum RBV [%]
82.5 ± 7.3
80.1 ± 7.2
80.3 ± 8.6
80.3 ± 8.3
82.4 ± 8.5
85.2 ± 7.4
<0.001
2 vs.6
1 vs .2-6
Haemoglobin post HDF [g/dL]
9.4 ± 2.7
10.1 ± 2.6
9.8 ± 2.8
9.7 ± 2.9
9.0 ± 2.7
8.4 ± 2.4
<0.0001
1 vs.2
1 vs.3-6
Haemoglobin pre HDF [g/dL]
7.2 ± 1.8
7.5 ± 1.9
7.2 ± 1.8
7.2 ± 2.0
6.8 ± 1.8
6.7 ± 1.8
<0.0001
2 vs.6
1 vs.2-6
pre HDF BWC [%]
86.4 ± 1.4
86.1 ± 1.6
86.4 ± 1.6
86.4 ± 1.8
86.7 ± 1.7
86.8 ± 1.6
NS
None
1 vs.2-6
post HDF BWC [%]
84.5 ± 2.3
83.9 ± 2.3
84.2 ± 2.4
84.3 ± 2.5
85.0 ± 2.1
85.4 ± 2.1
<0.0001
1 vs.5-6
1 vs.2-4
Δ Haemoglobin [g/dL]
2.2 ± 1.3
2.7 ± 1.4
2.6 ± 1.5
2.5 ± 1.4
2.2 ± 1.3
1.8 ± 1.0
<0.0001
1 vs.2-4
1 vs.5,6
Δ BWC [g/dL] 1.9 ± 1.1 2.2 ± 1.2 2.2 ± 1.3 2.1 ± 1.2 1.8 ± 1.1 1.4 ± 0.9 <0.0001 1 vs.2-4 1 vs.5,6.

Hemodiafiltration (HDF). Blood Water Component (BWC). Δ Hemoglobin = pre-post HDF, Δ BWC = pre – post HDF. Group 1: 0 to 7.53 liters, Group 2: 7.54 to 14.8 liters; Group 3: 14.9 to 16.96 liters; Group 4: 16.97 to 18.9 liters; Group 5: 19.1 to 21 liters, and Group 6: 21.1 to 30 liters.


[TableWrap ID: T4] Table 4 

Occurrence of intradialytic hypotension (IDH) during hemodiafiltration (HDF) treatments stratified into sixtiles according to the convective volume used


  Sixtiles of convective volume prescription
Total
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6
Treatments [count]
379
382
377
382
380
376
2276
no IDH [Count [%]]
348 [91.8%]
314 [82.2%]
324 [85.9%]
343 [89.8%]
347 [91.3%]
361 [96.0%]
2037 [89.5%]
IDH [Count [%]] 31 [8.2%] 68 [17.8%] 53 [14.1%] 39 [10.2%] 33 [8.7%] 15 [4.0%] 239 [10.5%]

Group 1: 0 to 7.53 liters, Group 2: 7.54 to 14.8 liters; Group 3: 14.9 to 16.96 liters; Group 4: 16.97 to 18.9 liters; Group 5: 19.1 to 21 liters, and Group 6: 21.1 to 30 liters.


[TableWrap ID: T5] Table 5 

Logistic regression analysis to determine odds ratio of hemodiafiltration volume for intradialytic hypotension (IDH)


a]
B
S.E.
Wald
df
Sig.
Exp[B]
95,0% C.I. for EXP[B]
              Lower Upper
Groups
 
 
43.31
5
<0.0001
1
 
 
Sixtil (1)
0.888
0.230
14.88
1
<0.0001
2.43
1.55
3.82
Sixtil (2)
0.608
0.239
6.47
1
0.011
1.84
1.15
2.93
Sixtil (3)
0.244
0.252
0.94
1
0.334
1.28
0.78
0.78
Sixtil (4)
0.065
0.261
0.06
1
0.802
1.07
0.64
1.78
Sixtil (5)
−0.763
0.323
5.56
1
0.018
0.47
0.25
0.88
Constant
−2.418
0.187
166.45
1
<0.0001
0.09
 
 
b]
B
S.E.
Wald
df
Sig.
Exp(B)
95% C.I.for EXP(B)
 
 
 
 
 
 
 
Lower
Upper
Groups
 
 
28.172
5
<0.0001
 
 
 
Sixtil (1)
0.726
0.247
8.598
1
0.003
2.066
1.272
3.356
Sixtil (2)
0.525
0.250
4.405
1
0.036
1.690
1.035
2.758
Sixtil (3)
0.140
0.263
0.285
1
0.594
1.151
0.687
1.926
Sixtil (4)
−0.058
0.277
0.044
1
0.834
0.944
0.549
1.623
Sixtil (5)
−0.679
0.330
4.247
1
0.039
0.507
0.266
0.967
Pre Systolic Blood Press
0.007
0.004
3.778
1
0.052
1.007
1.000
1.014
Pre Diastolic Blood Press
0.003
0.004
0.375
1
0.541
1.003
0.994
1.011
Albumine
−0.428
0.167
6.545
1
0.011
0.652
0.469
0.905
Ultrafiltration
0.0001
0.0001
12.316
1
<0.0001
1.000
1.000
1.000
Effective Dialysis Time
0.0001
0.004
0.005
1
0.945
1.000
0.992
1.008
Delta Temperature
0.023
0.107
0.048
1
0.827
1.024
0.830
1.262
Post Weight
−0.009
0.006
2.197
1
0.138
0.991
0.980
1.003
Constant −2.214 1.300 2.903 1 0.088 0.109    

Table 5a) shows the association between convective volume and the occurrence of IDH without adjustment, and b) shows the Odds ratio after adjustment for relevant parameters.

The groups of convective volume were defined as follows: Group 1: 0 to 7.53 liters, Group 2: 7.54 to 14.8 liters; Group 3: 14.9 to 16.96 liters; Group 4: 16.97 to 18.9 liters; Group 5: 19.1 to 21 liters, and Group 6: 21.1 to 30 liters.


[TableWrap ID: T6] Table 6 

Logistic regression analysis to determine Odds Ratio of hemodiafiltration volume for Intradialytic Hypotension


  B S.E. Wald Sig. Exp[B] 95,0% C.I. for EXP[B]
Lower Upper
Nhdfvol
 
 
43.328
<0.0001
 
 
 
Nhdfvol (1)
−0.115
0.760
0.023
0.879
0.891
0.201
3.952
Nhdfvol (2)
0.880
0.236
13.976
<0.0001
2.412
1.520
3.827
Nhdfvol (3)
0.600
0.244
6.045
0.014
1.822
1.129
2.939
Nhdfvol (4)
0.236
0.257
0.843
0.358
1.266
0.0765
2.096
Nhdfvol(5)
0.058
0.266
0.047
0.829
1.059
0.629
1.784
Nhdfvol (6)
−0.770
0.327
5.547
0.019
0.463
0.244
0.879
Constant −2.410 0.194 154.604 <0.0001 0.090    

The groups of convective volume were defined as follows: Group 1: 0 to 0.2 liters. Group 2: 0.3 to 7.53 liters, Group 3: 7.54 to 14.8 liters; Group 4: 14.9 to 16.96 liters; Group 5: 16.97 to 18.9 liters; Group 6: 19.1 to 21 liters, and Group 7: 21.1 to 30 liters.


[TableWrap ID: T7] Table 7 

Ultrafiltration rate by time


  Groups
Dunett Test
1 2 3 4 5 6 Total Anova P < 0.05 P > 0.05
UF rate 15 min (mL/min)
20 ± 14
23 ± 17
22 ± 17
26 ± 24
23 ± 20
23 ± 22
23 ± 19
<0.001
1 vs. 4.
1 vs 2,3,5,6
UF rate 30 min (mL/min)
20 ± 8
23 ± 9
21 ± 9
22 ± 9
20 ± 8
17 ± 8
20 ± 9
<0.0001
1 vs 2–4.
1 vs 5,6.
UF rate 45 min (mL/min)
18 ± 8
21 ± 8
19 ± 8
20 ± 9
18 ± 7
16 ± 8
19 ± 8
<0.0001
1 vs 2,4.
1 vs 3,5,6.
UF rate 60 min (mL/min)
16 ± 6
18 ± 8
17 ± 8
18 ± 7
17 ± 9
15 ± 6
17 ± 7
<0.0001
1 vs 2–4.
1 vs 5,6.
UF rate 75 min (mL/min)
14 ± 6
17 ± 6
15 ± 6
16 ± 6
15 ± 6
13 ± 6
15 ± 6
<0.0001
1 vs 2–4.
1 vs 5,6.
UF rate 90 min (mL/min)
12 ± 5
15 ± 6
14 ± 6
14 ± 5
13 ± 5
12 ± 5
13 ± 5
<0.0001
1 vs 2–5.
1 vs 6.
UF rate 105 min (mL/min)
11 ± 6
13 ± 6
13 ± 5
12 ± 5
12 ± 5
11 ± 4
12 ± 5
<0.0001
1 vs 2–4.
1 vs 5,6.
UF rate 120 min (mL/min)
10 ± 6
13 ± 6
12 ± 5
11 ± 5
11 ± 5
10 ± 4
11 ± 5
<0.0001
1 vs 2–4.
1 vs 5,6.
UF rate 135 min (mL/min)
10 ± 5
12 ± 5
11 ± 5
11 ± 5
10 ± 4
9 ± 4
10 ± 5
<0.0001
1 vs 2–4.
1 vs 5,6.
UF rate 150 min (mL/min)
9 ± 6
11 ± 6
10 ± 5
10 ± 5
9 ± 4
8 ± 4
9 ± 5
<0.0001
1 vs 2–4.
1 vs 5,6.
UR rate 165 min (mL/min)
8 ± 5
10 ± 5
9 ± 5
9 ± 5
8 ± 4
7 ± 4
9 ± 5
<0.0001
1 vs 2–4.
1 vs 5,6.
UF rate 180 min (mL/min)
8 ± 9
11 ± 9
10 ± 9
10 ± 10
8 ± 7
7 ± 5
9 ± 8
<0.0001
1 vs 2–4.
1 vs 5,6.
UF rate 210 min (mL/min) 9 ± 22 15 ± 22 11 ± 14 10 ± 9 10 ± 25 7 ± 8 10 ± 16 <0.0001 1 vs 2. 1 vs 3–6.

The groups of convective volume were defined as follows: Group 1: 0 to 0.2 liters. Group 2: 0.3 to 7.53 liters, Group 3: 7.54 to 14.8 liters; Group 4: 14.9 to 16.96 liters; Group 5: 16.97 to 18.9 liters; Group 6: 19.1 to 21 liters, and Group 7: 21.1 to 30 liters.



Article Categories:
  • Research Article

Keywords: Intradialytic hypotension, Hemodiafiltration, Convective volume.

Previous Document:  Pollen Morphology of the Platycodonoid Group (Campanulaceae s. str.) and Its Systematic Implications...
Next Document:  Genome-wide analysis of pain-, nerve- and neurotrophin -related gene expression in the degenerating ...