Novel Insights into the Pathogenesis and Prevention of Intradialytic Hypotension

Sande, Frank M. van der; Dekker, Marijke; Leunissen, Karel M.L.; Kooman, Jeroen P.

doi:10.1159/000485160

Cited by 29 publications

(18 citation statements)

References 45 publications

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“…Other factors that might influence the intestinal microbiota are the dietary restrictions imposed to these patients and also the dialysis procedure itself. Intradialytic hypotension, a common complication in hemodialysis patients, is known to result in regional hypo-perfusion that can also affect the gut mucosa 33,34. It is unknown whether this disturbance of the homeostatic environment also affects the composition of the intestinal microbiome and butyrate-producing species.…”

Section: Discussionmentioning

confidence: 99%

<p>Butyrate production in patients with end-stage renal disease</p>

Terpstra

Sinnige

Hugenholtz

et al. 2019

IJNRD

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Background: Chronic kidney disease (CKD) is associated with a decreased intestinal barrier function, causing bacterial translocation over the intestinal wall and triggering a systemic inflammatory response. Butyrate, a short-chain fatty acid produced by certain bacterial strains, is considered instrumental to keep the intestinal barrier intact. There are indications that a decreased amount of these specific bacterial species is part of the cause of the decreased intestinal barrier function in CKD. The aim of this study is (i) to determine if Dutch patients with end-stage renal disease (ESRD) have a decreased amount of butyrate-producing species and butyrate-producing capacity and (ii) whether this correlates with systemic inflammation. Methods: We used qPCR to evaluate the most abundant butyrate-producing species F. prauznitzii, E. rectale and Roseburia spp . and the BCoAT gene, which reflects the butyrogenic capacity of the intestinal microbiota. Fecal samples were collected from healthy kidney donors (n=15), preemptive renal transplant recipients (n=4) and dialysis patients (n=31). Markers of inflammation (CRP and IL-6) and intestinal permeability (D-lactate) were measured in plasma. Results: Patients with ESRD did not have a significantly decreased amount F. prauznitzii, E. rectale and Roseburia spp . or the BCoAT gene. Neither was there a significant correlation with CRP, IL-6 or D-lactate. On the individual level, there were some patients with decreased BCoAT levels and increased levels of CRP, IL-6 and D-lactate. Conclusions: Patients with ESRD do not have a decreased amount of the most abundant butyrate-producing species nor a decreased butyrate-producing capacity.

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Section: Discussionmentioning

confidence: 99%

<p>Butyrate production in patients with end-stage renal disease</p>

Terpstra

Sinnige

Hugenholtz

et al. 2019

IJNRD

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“…The pathogenesis of IDH includes a multitude of factors related to the dialysis prescription, process of care, such as sedation, patient comorbidities, and severity of illness. During the therapy of ultra ltration, plasma volume decreases and oncotic pressure rises 16 . Plasma re lling, which is the shift of uid from the interstitial and intracellular compartments to the intravascular compartment, is favored by the resulting rise in oncotic pressure.…”

Section: Discussionmentioning

confidence: 99%

A Randomized Trial of Albumin Infusion to Prevent Intradialytic Hypotension in Hypoalbuminemic Patients

Macedo¹,

Karl²,

Lee³

et al. 2020

Preprint

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Background: Intradialytic hypotension (IDH) is a frequent complication of intermittent hemodialysis (IHD), occurring from 15 to 50% of ambulatory sessions, and is more frequent among hospitalized patients with hypoalbuminemia 1. IDH limits adequate fluid removal and increases the risk for vascular access thrombosis, early hemodialysis (HD) termination, and mortality. Albumin infusion before and during therapy has been used for treating IDH with varying results. We evaluated the efficacy of albumin infusion in preventing IDH during IHD in hypoalbuminemic inpatients. Methods: A randomized, crossover trial was performed in 65 AKI or ESRD patients with hypoalbuminemia (albumin<3g/dl) who required HD during hospitalization. Patients were randomized to receive 100ml of either 0.9%sodium chloride or 25% albumin intravenously at the initiation of each dialysis. These two solutions were alternated for up to 6 sessions. Patients’ vital signs and ultrafiltration removal rate were recorded every 15 to 30 minutes during dialysis. IDH was assessed by different definitions reported in the literature. All symptoms associated with a noted hypotensive event as well as interventions during the dialysis were recorded. Results: 65 patients were submitted to 249 sessions; mean age was 58 (+/-12), 46 (70%) were male with a mean weight of 76 (+/-18) kg. Presence of IDH was lower during albumin sessions based on all definitions. The risk of hypotension was significantly decreased based on the Kidney Disease Outcomes Quality Initiative (KDOQI) definition; (15% with NS vs. 7% with albumin, p=0.002). Lowest intradialytic SBP was significantly worse in patients that received 0.9% sodium chloride in comparison to albumin (NS 83 vs. Albumin 90 mmHg,p = 0.035). Overall ultrafiltration rate was significantly higher in the albumin therapies (NS -8.25 ml/kg/h (-11.18 -5.80) vs. 8.27ml/kg/h (-12.22 - 5.53) with albumin, p =0.011). Conclusion: In hypoalbuminemic patients who need HD, administration of albumin before dialysis results in fewer episodes of hypotension and improves fluid removal. Albumin infusion may be of benefit to improve safety of HD and achievement of fluid balance in these high-risk patients.ClinicalTrials.gov Identifier: NCT04522635Retrospectively registered in August 21, 2020

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“…The question as to why it is so difficult to achieve normovolemia in daily clinical practice arises due to an imbalance between fluid and sodium intake, and the possibility to remove fluid adequately despite the discontinuity, which is an integral component of HD. This problem is likely augmented in patients with substantial comorbidity and/or cardiac dysfunction [47,48]. To make matters even more complex, pre-dialytic fluid depletion is associated with increased mortality as compared to patients with normovolemia, whereas post-dialytic fluid depletion was associated with a better outcome as compared to post-dialytic normovolemia [2].…”

Section: The Dry Weight Conceptmentioning

confidence: 99%

Body Fluids in End-Stage Renal Disease: Statics and Dynamics

Kooman

Sande²

2018

Blood Purif

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Background: Abnormalities in fluid status in hemodialysis (HD) patients are highly prevalent and are related to adverse outcomes. Summary: The inherent discontinuity of the HD procedure in combination with an often compromised cardiovascular response is a major contributor to this phenomenon. In addition, systemic inflammation and endothelial dysfunction are related to extracellular fluid overload (FO). Underlying this relation may be factors such as hypoalbuminemia and an increased capillary permeability, leading to an altered fluid distribution between the blood volume (BV) and the interstitial fluid compartments, compromising fluid removal during dialysis. Indeed, whereas estimates of extracellular volume by bioimpedance spectroscopy are highly predictive of mortality, absolute BV assessed by the saline dilution technique was predictive of intra-dialytic morbidity. Changes in relative BV during HD are positively related to ultrafiltration rate (UFR) and, at least in some studies, negatively to FO. High UFR is also related to changes in central venous oxygen saturation (S_cvO₂), a marker for tissue perfusion. On the one hand, high UFR and more pronounced declines in S_cvO₂, but on the other hand, flat relative BV curves are also predictive of mortality; the relation between outcome which statics and dynamics of fluid status appears to be complex. Key Message: While technological developments enable the clinician to monitor statics and dynamics of fluid status and hemodynamics during HD in an accessible way, the role of technology-based interventions needs further study.

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Novel Insights into the Pathogenesis and Prevention of Intradialytic Hypotension

Cited by 29 publications

References 45 publications

<p>Butyrate production in patients with end-stage renal disease</p>

<p>Butyrate production in patients with end-stage renal disease</p>

A Randomized Trial of Albumin Infusion to Prevent Intradialytic Hypotension in Hypoalbuminemic Patients

Body Fluids in End-Stage Renal Disease: Statics and Dynamics

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