Circulating Endotoxaemia and Frequent Haemodialysis Schedules

Jefferies, Helen J.; Crowley, Lisa; Harrison, L.; Szeto, Cheuk‐Chun; Li, Philip K.T.; Schiller, Brigitte; Moran, John; McIntyre, Christopher W.

doi:10.1159/000366519

Cited by 27 publications

(23 citation statements)

References 27 publications

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“…Our results also integrate with the findings by McIntyre and colleagues, who hypothesized that hemodialysis-induced systemic circulatory stress and recurrent bowel ischemia may lead to increased endotoxin translocation from intestine (23,24). Their studies demonstrated that patients on hemodialysis have six-fold higher levels of circulating endotoxin than patients on peritoneal dialysis or with nondialysis-dependent patients with CKD, and that endotoxin levels were higher among patients with more dialysis-induced BP instability (23).…”

Section: Discussionsupporting

confidence: 90%

“…Their studies demonstrated that patients on hemodialysis have six-fold higher levels of circulating endotoxin than patients on peritoneal dialysis or with nondialysis-dependent patients with CKD, and that endotoxin levels were higher among patients with more dialysis-induced BP instability (23). Conversely, patients who had more frequent hemodialysis and less BP instability had lower circulating endotoxin levels (24).…”

Section: Discussionmentioning

confidence: 99%

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The Relationship between Intradialytic Hypotension and Hospitalized Mesenteric Ischemia

Seong

Zheng

Winkelmayer

et al. 2018

CJASN

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Background and objectives Mesenteric ischemia is a rare but devastating condition caused by insufficient blood supply to meet the demands of intestinal metabolism. In patients with ESKD, it can be difficult to diagnose and has a .70% mortality rate. Patients on hemodialysis have a high prevalence of predisposing conditions for mesenteric ischemia, but the contribution of intradialytic hypotension, a potential modifiable risk factor, has not been well described.Design, setting, participants, & measurements We used data from the US Renal Data System to identify 626 patients on hemodialysis with a hospitalized mesenteric ischemia event (cases). We selected 2428 controls in up to a 1:4 ratio matched by age, sex, black race, incident dialysis year, diabetes mellitus, coronary artery disease, and peripheral artery disease. We used six different definitions of intradialytic hypotension on the basis of prior studies, and categorized patients as having had intradialytic hypotension if $30% of hemodialysis sessions in the 30 days before the event met the specified definition. ResultsThe proportion of patients with intradialytic hypotension varied depending on its definition: from 19% to 92% of cases and 11% to 94% of controls. Cases had a higher adjusted odds (1.82; 95% confidence interval, 1.47 to 2.26) of having had intradialytic hypotension in the preceding 30 days than controls when using nadir-based intradialytic hypotension definitions such as nadir systolic BP ,90 mm Hg. To examine a potential dose-response association of intradialytic hypotension with hospitalized mesenteric ischemia, we categorized patients by the proportion of hemodialysis sessions having intradialytic hypotension, defined using the Nadir90 definition (0%, 1%-9%, 10%-29%, 30%-49%, and $50%), and found a direct association of proportion of intradialytic hypotension with hospitalized mesenteric ischemia (P-trend,0.001).Conclusions Patients with hospitalized mesenteric ischemia had significantly higher odds of having had intradialytic hypotension in the preceding 30 days than controls, as defined by nadir-based definitions.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

The Relationship between Intradialytic Hypotension and Hospitalized Mesenteric Ischemia

Seong

Zheng

Winkelmayer

et al. 2018

CJASN

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“…66 Patients receiving conventional thrice weekly hemodialysis had higher predialysis serum endotoxin level than those receiving short daily hemodialysis or nocturnal hemodialysis, even after adjusting for age and diabetic status. 67 Relation with CVD in CKD Two studies have reported that plasma endotoxin level correlates with ultrafiltration rate in patients on hemodialysis 67 and the drop in systolic BP during hemodialysis treatment. 66 Plasma endotoxin level of patients on hemodialysis also correlates with cardiac troponin T and CRP levels.…”

Section: Pathogenic Mechanismsmentioning

confidence: 99%

Circulating Bacterial Fragments as Cardiovascular Risk Factors in CKD

Szeto

McIntyre

2018

JASN

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Cardiovascular disease (CVD) is a major cause of mortality and morbidity in patients with CKD. In the past decade, intestinal dysbiosis and altered gut epithelial barrier function are increasingly recognized in CKD. Uremic patients have slow intestinal transit time, impaired protein assimilation, and decreased consumption of dietary fiber. The use of multiple medications also may contribute to the proliferation of dysbiotic bacteria, which affect the barrier function of intestinal epithelium. In addition, fluid overload and uremic toxins directly reduce the gut barrier function. The major consequence of these alterations, the translocation of bacterial fragments from bowel lumen to systemic circulation, can lead to diverse biologic effects and probably represents an important nontraditional CVD risk factor in CKD. Among all bacterial fragments, endotoxin is the most well studied. Plasma endotoxin levels are markedly elevated in both patients with CKD and those on dialysis, and are associated with the systemic inflammatory state, accelerated atherosclerosis, and clinical CVD in patients on dialysis. Optimization of BP control and the use of ultrapure dialysate can reduce plasma endotoxin levels, with probable metabolic and cardiovascular benefits. The benefit of synbiotic therapy is not confirmed, although results from animal studies are impressive. The biologic effects and clinical relevance of other bacterial fragments, such as bacterial DNA fragments, are less well defined. Further studies are needed to delineate the pathogenic relation between circulating bacterial fragments and CVD, and to define the role of the plasma bacterial fragment level as a prognostic indicator of CKD.

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“…43, 44 Repetitive insults and stunning may then lead to ventricular remodeling and the effects of heart failure 44–46 when ejection fraction declines. This ultrafiltration induce hypotension may also lead to ischemia to other organs including the brain 47 , GI tract 48, 49 and kidney. Intradialytic hypotension with ischemia to the kidney may also be a contributing factor to further loss of residual kidney function 50 which would result in more difficulties with volume management for HD patients.…”

Section: Approach To Fluid Management In Hd Patientsmentioning

confidence: 99%

Volume Balance and Intradialytic Ultrafiltration Rate in the Hemodialysis Patient

Chou

Kalantar-Zadeh

2017

Curr Heart Fail Rep

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PURPOSE OF REVIEW Volume management in hemodialysis patients is often challenging. Assessing volume status and deciding how much fluid to remove during hemodialysis, the so-called ultrafiltration rate (UFR), has remained a conundrum. RECENT FINDINGS To date there is no objective assessment tool to determine the needed UFR during each hemodialysis session. Higher volume overload or higher UFR is associated with poor outcomes including worse mortality and unfavorable clinical outcomes. We suggest combined use of the following criteria to determine UFR or post-dialysis target dry weight: pre-hemodialysis blood pressure and its intradialytic changes, muscle cramps, dyspnea from pulmonary vascular congestion, peripheral edema, tachycardia or palpitation, headache or lightheadedness, perspiration, post-dialysis fatigue. Restricting fluid and salt intake – and high-dose loop diuretic use in case of residual kidney function – can be helpful in controlling fluid gains. More frequent and more severe hypotensive episodes are associated with poor outcomes including higher death risk.

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Circulating Endotoxaemia and Frequent Haemodialysis Schedules

Cited by 27 publications

References 27 publications

The Relationship between Intradialytic Hypotension and Hospitalized Mesenteric Ischemia

The Relationship between Intradialytic Hypotension and Hospitalized Mesenteric Ischemia

Circulating Bacterial Fragments as Cardiovascular Risk Factors in CKD

Volume Balance and Intradialytic Ultrafiltration Rate in the Hemodialysis Patient

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