Diuretics, Limited Ultrafiltration, and Residual Renal Function in Incident Hemodialysis Patients: A Case Series

Sjölund, Jessica; Anton, D; Bayes, Liz; Hoekstra, Tiny; Dekker, Friedo W.; Mendoza, Jair Munoz

doi:10.1111/sdi.12508

Cited by 9 publications

(8 citation statements)

References 28 publications

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“…However, higher UF causes greater hemodynamic stress 49 and increases IDH incidence, an independent predictor of RRF decline. 36,50 This coincides with our findings, where DRP severity was associated with mean and total UF (r=0.31; P,0.05 and r=0.26; P=0.05, respectively), suggesting that UF-induced ischemic injury may be a key factor in progressive RRF loss in patients on HD. This establishes a vicious cycle of HD-induced RRF decline, followed by a necessitated increase in UF, followed again by RRF decline, in keeping with the observed rapid decline shortly after HD initiation.…”

Section: Relationship To Dialysis Stress Factors Standard Hdsupporting

confidence: 91%

“…The role of HD-mediated hemodynamic instability and transient renal ischemia in progressive RRF decline in patients on HD has been alluded to previously. 10,11,26,36,37 However, this is the first study to directly measure intradialytic renal perfusion and confirm that DRP represents the first key step toward characterizing RRF loss in patients on HD.…”

Section: Relationship Between Renal Perfusion Myocardial Stunning and mentioning

confidence: 68%

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Renal Perfusion during Hemodialysis: Intradialytic Blood Flow Decline and Effects of Dialysate Cooling

Marants

Qirjazi

Grant

et al. 2019

JASN

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BackgroundResidual renal function (RRF) confers survival in patients with ESRD but declines after initiating hemodialysis. Previous research shows that dialysate cooling reduces hemodialysis-induced circulatory stress and protects the brain and heart from ischemic injury. Whether hemodialysis-induced circulatory stress affects renal perfusion, and if it can be ameliorated with dialysate cooling to potentially reduce RRF loss, is unknown.MethodsWe used renal computed tomography perfusion imaging to scan 29 patients undergoing continuous dialysis under standard (36.5°C dialysate temperature) conditions; we also scanned another 15 patients under both standard and cooled (35.0°C) conditions. Imaging was performed immediately before, 3 hours into, and 15 minutes after hemodialysis sessions. We used perfusion maps to quantify renal perfusion. To provide a reference to another organ vulnerable to hemodialysis-induced ischemic injury, we also used echocardiography to assess intradialytic myocardial stunning.ResultsDuring standard hemodialysis, renal perfusion decreased 18.4% (P<0.005) and correlated with myocardial injury (r=−0.33; P<0.05). During sessions with dialysis cooling, patients experienced a 10.6% decrease in perfusion (not significantly different from the decline with standard hemodialysis), and ten of the 15 patients showed improved or no effect on myocardial stunning.ConclusionsThis study shows an acute decrease in renal perfusion during hemodialysis, a first step toward pathophysiologic characterization of hemodialysis-mediated RRF decline. Dialysate cooling ameliorated this decline but this effect did not reach statistical significance. Further study is needed to explore the potential of dialysate cooling as a therapeutic approach to slow RRF decline.

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Section: Relationship To Dialysis Stress Factors Standard Hdsupporting

confidence: 91%

Section: Relationship Between Renal Perfusion Myocardial Stunning and mentioning

confidence: 68%

Renal Perfusion during Hemodialysis: Intradialytic Blood Flow Decline and Effects of Dialysate Cooling

Marants

Qirjazi

Grant

et al. 2019

JASN

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“…A practice of twice a week hemodialysis supplemented with diuretics may be of special benefit in the elderly with limited mobility to get to the HD unit. A recent study suggests that lower ultrafiltration in combination with a large dose diuretic use may help slow the decline in endogenous renal function for the first two years after dialysis initiation [ 41 ]. The majority of respondents felt that multiple causes lead to HTN in HD not just increased volume.…”

Section: Discussionmentioning

confidence: 99%

Practice patterns in transitioning patients from chronic kidney disease to dialysis: a survey of United States nephrologists

et al. 2018

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BackgroundThere are no guidelines for transitioning patients from chronic kidney disease stage 5 to hemodialysis. We conducted this study to determine if there are uniform patterns in how nephrologists transition patients to dialysis.MethodsWe designed an electronic survey with 39 questions and sent it to a database of practicing nephrologists at the National Kidney Foundation. Factors that were important for transitioning a patient to hemodialysis were evaluated, including medication changes on dialysis initiation, dry weight and dialysis prescription.Results160 US Nephrologists replied to the survey; 18% (29/160) of the responses were completed via social media sites. Prior to dialysis, 74% (118/160), prescribed furosemide and 67% (107/160) used furosemide with metolazone. Once dialysis started, only 46% (74/160) of the responders continued patients on diuretics daily. Hypertension medications prescribed in dialysis were calcium channel blockers 69% (112/160), beta blockers 36% (58/160), angiotensin converting enzyme inhibitor 32% (53/160), angiotensin receptor blocker 29% (46/160) and diuretics 25% (42/160). Once dialysis started, 68% (109/160) routinely changed medications. Most, 67% (107/160) ordered patients to avoid anti-hypertensive medications on dialysis days to allow for ultrafiltration. Dry weight was determined in the first week by 29% (46/160) and in the first month by 53% (85/160). Most, 59% (94/160) felt that multiple causes lead to hypertension. Most nephrologists would prescribe small dialyzers and a shorter period of time for the first dialysis session.ConclusionThe transition period to chronic hemodialysis has variations in practice patterns and may benefit from further studies to optimize clinical practice.Electronic supplementary materialThe online version of this article (10.1186/s12882-018-0943-0) contains supplementary material, which is available to authorized users.

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“…Diuretic use has been shown to be low upon initiation of dialysis due to the belief that dialysis patients do not have significant urine volume [60]. Previous studies have shown that diuretics affect water and sodium excretion in patients with end stage renal disease but the effects on preserving residual renal volume in such patients is limited [61-64]. Presently, data is limited on role of diuretics in patients with heart failure and end stage renal disease.…”

Section: New Drugsmentioning

confidence: 99%

Therapeutic Approach to Patients with Heart Failure with Reduced Ejection Fraction and End-stage Renal Disease

Inampudi

Álvarez

Asleh

et al. 2018

CCR

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Maintenance of interdialytic and intradialytic euvolemia is a key component of HF management in these patients but often difficult to achieve. Beta-blockers, especially carvedilol which is poorly dialyzed is associated with cardiovascular benefit in this population. Despite paucity of data, Angiotensin-converting Enzyme Inhibitors (ACEI) or Angiotensin II Receptor Blockers (ARBs) when appropriately adjusted by dose and with close monitoring of serum potassium can also be administered to these patients who tolerate beta-blockers. Mineralocorticoid receptors in patients with HFrEF and ESRD have been shown to reduce mortality in a large randomized controlled trial without any significantly increased risk of hyperkalemia. Implantable Cardiac-defibrillators (ICDs) should be considered for primary prevention of sudden cardiac death in patients with HFrEF and ESRD who meet the implant indications. Furthermore in anemic iron-deficient patients, intravenous iron infusion may improve functional status. Finally, mechanical circulatory support with leftventricular assist devices may be related to increased mortality risk and the presence of ESRD poses a relative contraindication to further evaluation of these devices.

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Diuretics, Limited Ultrafiltration, and Residual Renal Function in Incident Hemodialysis Patients: A Case Series

Cited by 9 publications

References 28 publications

Renal Perfusion during Hemodialysis: Intradialytic Blood Flow Decline and Effects of Dialysate Cooling

Renal Perfusion during Hemodialysis: Intradialytic Blood Flow Decline and Effects of Dialysate Cooling

Practice patterns in transitioning patients from chronic kidney disease to dialysis: a survey of United States nephrologists

Therapeutic Approach to Patients with Heart Failure with Reduced Ejection Fraction and End-stage Renal Disease

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