Impact of Profile Haemodialysis on Intra-/Extracellular Fluid Shifts and the Release of Vasoactive Hormones in Elderly Patients on Regular Dialysis Treatment

Abstract

In 15 patients with end-stage renal failure and proven coronary heart disease, profile haemodialysis with decreasing ultrafiltration rate and hyperionic, decreasing dialysate solute concentration was compared with conventional, extracorporeal bicarbonate haemodialysis (Na⁺_D =138 mmol/l). Body fluid distribution and the release of vasoactive hormones (plasma renin activity, aldosterone, norepinephrine, epinephrine, and atrial natriuretic peptide) were investigated. Haemodialysis with constant ultrafiltration rate and constant dialysate composition (A) was followed by two dialysis profiles: decreasing ultrafiltration rate (B) and additional hyperionic, decreasing dialysate sodium concentration (C). In all 15 patients, the dialysis procedures (A) – (C) were used for 2 weeks each with six sessions, the last being taken for investigation. Body fluid distribution was calculated. In patients with serum sodium above 136 mmol/l, the conventional dialysis (A) as well as the Uf profile (B) showed a net fluid shift from extracellular volume (ECV) to intracellular volume (ICV). Using the profile with hyperionic, decreasing Na⁺D (C), the reverse fluid shift with decreasing ICV was achieved not only in those with serum Na⁺ < 136 mmol/l, but also in those with serum Na⁺ ≥ 136 mmol/l. The release of vasoactive hormones decreased already at profile haemodialysis (B) compared with (A) and was further reduced in (C). These results would suggest, profile dialyses B and C to have less impact on the cardiovascular system in elderly patients assuming higher patient comfort compared with the standard dialysis procedure. A higher benefit was obtained in C compared with B, presumably due to the additional prevention of the ICV shift and plasma volume depletion in patients with initial serum sodium ≥ 136 mmol/l using transiently hyperionic Na⁺_D. These results show that in elderly patients, hyperionic profile haemodialysis (Na⁺_D > Na⁺s) had less impact on cardiovascular regulation than conventional bicarbonate dialysis.

Intradialytic hypotension

“…Combined UF profile with a sodium profile with a dialysate sodium 10% higher than the pre-dialysis plasma sodium, decreased in five steps to 138 mmol/ l in the last hour Both the standalone UF and sodium profiles were associated with intradialytic symptoms and hypotension. The combined profiles improved the UF potential in association with reduced renin, aldosterone, and epinephrine and norepinephrine levels [68], and the authors postulated that this reflected improved vascular stability. Song et al selected adult patients who were prone to IDH and found that profiles that resulted in a positive sodium balance (time-averaged dialysate Na concentration of 143 mEq/l) improved UF performance (ability to achieve the UF goal, premature discontinuation of treatment), but left the patients feeling thirsty, with increased interdialytic weight gain and worsening hypertension.…”

Evaluating methods for improving ultrafiltration in pediatric hemodialysis

“…One aspect of this is ultrafiltration (UF), although the ability to remove desired target volumes can be hindered by the development of intradialytic symptoms and hypotension [3]. There are reports of improved hemodynamic stability with the use of UF profiles, either alone [4] or in combination with sodium profiles [5][6][7], and improved UF with sequential hypertonic HD [8]. However, there are few data evaluating recent dialysis technical advances in children [9][10][11], and only one that evaluates UF profiles [12].…”

Rationale and design of the Sodium Lowering In Dialysate (SoLID) trial: a randomised controlled trial of low versus standard dialysate sodium concentration during hemodialysis for regression of left ventricular mass

“…Moreover, elevation in plasma [Na+] can induce hypertension independently of EC fluid volume, through mechanisms that probably include stiffening of vascular endothelium [42-46]. A number of observational studies as well as small and often uncontrolled clinical studies have shown that lower dialysate [Na+] associates with less thirst [47-55], lower IDWG [48,49,51-53,56-78], lower ECF volume [66,76,79,80], and lower BP [48,51,54,56,61-69,75,81-83], with only a minority of studies being completely negative [47,77,84-88]. A typical example can be found in preliminary research by the SoLID trial research team, who previously showed that a decrease in dialysate [Na+] by 3 mM in 52 facility based patients was well tolerated and reduced systolic and diastolic BP by 4–5 and 2–3 mmHg, respectively [89].…”