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Hemodynamic Instability During Continuous Renal Replacement Therapy: Is It All About Fluid?

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Annual Update in Intensive Care and Emergency Medicine 2022

Part of the book series: Annual Update in Intensive Care and Emergency Medicine ((AUICEM))

Abstract

Acute kidney injury (AKI) requiring treatment with renal replacement therapies is common in the critically ill, during which periods of hemodynamic instability, often manifest as a decrease in blood pressure, are frequently observed. The reported incidence of such episodes of hypotension varies considerably due, in part, to a lack of consensus as to what defines hemodynamic instability under such circumstances, as well as other factors, including treatment modality employed, and characteristics of the patient group under scrutiny. Historically, much of the limited understanding as to the mechanisms behind these observations comes from the chronic dialysis population where excessive volume removal may underpin falls in blood pressure. However, this may well be an oversimplification of the pathophysiology behind such hypotension observed on the intensive care unit, where excessive ultrafiltration for example, may not be the cause of the observed hemodynamic disequilibrium. Here we describe our current understanding regarding hemodynamic instability associated with renal replacement therapy as well as the epidemiology of this phenomenon.

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References

  1. Pannu N, Gibney RN. Renal replacement therapy in the intensive care unit. Ther Clin Risk Manag. 2005;1:141–50.

    Article  CAS  Google Scholar 

  2. Forni LG, Hilton PJ. Continuous hemofiltration in the treatment of acute renal failure. N Engl J Med. 1997;336:1303–9.

    Article  CAS  Google Scholar 

  3. Bagshaw SM, Berthiaume LR, Delaney A, Bellomo R. Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: a meta-analysis. Crit Care Med. 2008;36:610–7.

    Article  Google Scholar 

  4. Rabindranath KS, Adams J, MacLeod AM, Muirhead N. Intermittent versus continuous renal replacement therapy for acute renal failure in adults. Cochrane Database Syst Rev. 2007:CD003773.

    Google Scholar 

  5. Tonelli M, Astephen P, Andreou P, Beed S, Lundrigan P, Jindal K. Blood volume monitoring in intermittent hemodialysis for acute renal failure. Kidney Int. 2002;62:1075–80.

    Article  Google Scholar 

  6. Bitker L, Bayle F, Yonis H, et al. Prevalence and risk factors of hypotension associated with preload-dependence during intermittent hemodialysis in critically ill patients. Crit Care. 2016;20:44.

    Article  Google Scholar 

  7. Uchino S, Bellomo R, Morimatsu H, et al. Continuous renal replacement therapy: a worldwide practice survey. The beginning and ending supportive therapy for the kidney (B.E.S.T. kidney) investigators. Intensive Care Med. 2007;33:1563–70.

    Article  Google Scholar 

  8. Akhoundi A, Singh B, Vela M, et al. Incidence of adverse events during continuous renal replacement therapy. Blood Purif. 2015;39:333–9.

    Article  CAS  Google Scholar 

  9. Workgroup KD. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis. 2005;45:S1–S153.

    Google Scholar 

  10. Flythe JE, Chang TI, Gallagher MP, et al. Blood pressure and volume management in dialysis: conclusions from a kidney disease: improving global outcomes (KDIGO) controversies conference. Kidney Int. 2020;97:861–76.

    Article  Google Scholar 

  11. Silversides JA, Pinto R, Kuint R, et al. Fluid balance, intradialytic hypotension, and outcomes in critically ill patients undergoing renal replacement therapy: a cohort study. Crit Care. 2014;18:1–10.

    Article  Google Scholar 

  12. Flythe JE, Xue H, Lynch KE, Curhan GC, Brunelli SM. Association of mortality risk with various definitions of intradialytic hypotension. J Am Soc Nephrol. 2015;26:724–34.

    Article  CAS  Google Scholar 

  13. Assimon MM, Wenger JB, Wang L, Flythe JE. Ultrafiltration rate and mortality in maintenance hemodialysis patients. Am J Kidney Dis. 2016;68:911–22.

    Article  Google Scholar 

  14. Chazot G, Bitker L, Mezidi M, et al. Prevalence and risk factors of hemodynamic instability associated with preload-dependence during continuous renal replacement therapy in a prospective observational cohort of critically ill patients. Ann Intensive Care. 2021;11:1–12.

    Article  Google Scholar 

  15. Mc Causland FR, Waikar SS. Association of predialysis calculated plasma osmolarity with intradialytic blood pressure decline. Am J Kidney Dis. 2015;66:499–506.

    Article  CAS  Google Scholar 

  16. Lima EQ, Silva RG, Donadi EL, Fernandes AB, Zanon JR, Pinto KR, Burdmann EA. Prevention of intradialytic hypotension in patients with acute kidney injury submitted to sustained low-efficiency dialysis. Ren Fail. 2012;34:1238–43.

    Article  CAS  Google Scholar 

  17. Paganini E, Sandy D, Moreno L, Kozlowski L, Sakai K. The effect of sodium and ultrafiltration modelling on plasma volume changes and haemodynamic stability in intensive care patients receiving haemodialysis for acute renal failure: a prospective, stratified, randomized, cross-over study. Nephrol Dial Transplant. 1996;11(Suppl 8):32–7.

    Article  Google Scholar 

  18. Nicholson J, Wolmarans M, Park G. The role of albumin in critical illness. Br J Anaesth. 2000;85:599–610.

    Article  CAS  Google Scholar 

  19. Macedo E, Karl B, Lee E, Mehta RL. A randomized trial of albumin infusion to prevent intradialytic hypotension in hospitalized hypoalbuminemic patients. Crit Care. 2021;25:1–8.

    Article  Google Scholar 

  20. Clark E, McIntyre L, Watpool I, et al. Intravenous albumin for the prevention of hemodynamic instability during sustained low-efficiency dialysis. A randomized controlled feasibility trial (the SAFER-SLED study). Ann Intensive Care. 2021;11:174.

    Google Scholar 

  21. Selby NM, McIntyre CW. A systematic review of the clinical effects of reducing dialysate fluid temperature. Nephrol Dial Transplant. 2006;21:1883–98.

    Article  Google Scholar 

  22. Mustafa RA, Bdair F, Akl EA, et al. Effect of lowering the dialysate temperature in chronic hemodialysis: a systematic review and meta-analysis. Clin J Am Soc Nephrol. 2016;11:442–57.

    Article  Google Scholar 

  23. Sherman RA, Bialy GB, GazinskiL B, Bernholc AS, Eisinger RP. The effect of dialysate calcium levels on blood pressure during hemodialysis. Am J Kidney Dis. 1986;8:244–7.

    Article  CAS  Google Scholar 

  24. Langote A, Ahearn M, Zimmerman D. Dialysate calcium concentration, mineral metabolism disorders, and cardiovascular disease: deciding the hemodialysis bath. Am J Kidney Dis. 2015;66:348–58.

    Article  CAS  Google Scholar 

  25. Gabutti L, Salvadé I, Lucchini B, Soldini D, Burnier M. Haemodynamic consequences of changing potassium concentrations in haemodialysis fluids. BMC Nephrol. 2011;12:1–8.

    Article  Google Scholar 

  26. Douvris A, Zeid K, Hiremath S, et al. Mechanisms for hemodynamic instability related to renal replacement therapy: a narrative review. Intensive Care Med. 2019;45:1333–46.

    Article  Google Scholar 

  27. Selby NM, Burton JO, Chesterton LJ, McIntyre CW. Dialysis-induced regional left ventricular dysfunction is ameliorated by cooling the dialysate. Clin J Am Soc Nephrol. 2006;1:1216–25.

    Article  Google Scholar 

  28. Jefferies HJ, Burton JO, McIntyre CW. Individualised dialysate temperature improves intradialytic haemodynamics and abrogates haemodialysis-induced myocardial stunning, without compromising tolerability. Blood Purif. 2011;32:63–8.

    Article  Google Scholar 

  29. Odudu A, Eldehni MT, McCann GP, McIntyre CW. Randomized controlled trial of individualized dialysate cooling for cardiac protection in hemodialysis patients. Clin J Am Soc Nephrol. 2015;10:1408–17.

    Article  Google Scholar 

  30. Assa S, Hummel YM, Voors AA, Kuipers J, Westerhuis R, de Jong PE, Franssen CF. Hemodialysis-induced regional left ventricular systolic dysfunction: prevalence, patient and dialysis treatment-related factors, and prognostic significance. Clin J Am Soc Nephrol. 2012;7:1615–23.

    Article  CAS  Google Scholar 

  31. Mahmoud H, Forni LG, McIntyre CW, Selby NM. Myocardial stunning occurs during intermittent haemodialysis for acute kidney injury. Intensive Care Med. 2017;43:942–4.

    Article  Google Scholar 

  32. Slessarev M, Salerno F, Ball IM, McIntyre CW. Continuous renal replacement therapy is associated with acute cardiac stunning in critically ill patients. Hemodial Int. 2019;23:325–32.

    PubMed  Google Scholar 

  33. Burton JO, Jefferies HJ, Selby NM, McIntyre CW. Hemodialysis-induced repetitive myocardial injury results in global and segmental reduction in systolic cardiac function. Clin J Am Soc Nephrol. 2009;4:1925–31.

    Article  Google Scholar 

  34. Schortgen FDR, Soubrier N, Delclaux C, et al. Hemodynamic tolerance of intermittent hemodialysis in critically ill patients: usefulness of practice guidelines. Am J Respir Crit Care Med. 2000;162:197–202.

    Article  CAS  Google Scholar 

  35. Mitra S, Chamney P, Greenwood R, Farrington K. The relationship between systemic and whole-body hematocrit is not constant during ultrafiltration on hemodialysis. J Am Soc Nephrol. 2004;15:463–9.

    Article  Google Scholar 

  36. Pierro ML, Kainerstorfer JM, Civiletto A, Weiner DE, Sassaroli A, Hallacoglu B, Fantini S. Reduced speed of microvascular blood flow in hemodialysis patients versus healthy controls: a coherent hemodynamics spectroscopy study. J Biomed Opt. 2014;19:026005.

    Article  Google Scholar 

  37. Martinez AH, Diez GR, Ferraris V, et al. Removal of nitrate and nitrite by hemodialysis in end-stage renal disease and by sustained low-efficiency dialysis in acute kidney injury. Nitric Oxide. 2020;98:33–40.

    Article  CAS  Google Scholar 

  38. Bryan NS, Torregrossa AC, Mian AI, Berkson DL, Westby CM, Moncrief JW. Acute effects of hemodialysis on nitrite and nitrate: potential cardiovascular implications in dialysis patients. Free Radic Biol Med. 2013;58:46–51.

    Article  CAS  Google Scholar 

  39. Meyer C, Heiss C, Drexhage C, et al. Hemodialysis-induced release of hemoglobin limits nitric oxide bioavailability and impairs vascular function. J Am Coll Cardiol. 2010;55:454–9.

    Article  CAS  Google Scholar 

  40. Premont RT, Reynolds JD, Zhang R, Stamler JS. Role of nitric oxide carried by hemoglobin in cardiovascular physiology: developments on a three-gas respiratory cycle. Circ Res. 2020;126:129–58.

    Article  CAS  Google Scholar 

  41. Murugan R, Balakumar V, Kerti SJ, et al. Net ultrafiltration intensity and mortality in critically ill patients with fluid overload. Crit Care. 2018;22:223.

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Critical Care, Royal Surrey Hospital, Guildford, Surrey, UK

    S. M. T. Nasser, N. Boyer & L. G. Forni

  2. SPACeR Group (Surrey Peri-Operative, Anaesthesia & Critical Care Collaborative Research Group), Royal Surrey Hospital, Guildford, Surrey, UK

    S. M. T. Nasser, N. Boyer & L. G. Forni

  3. Department of Clinical & Experimental Medicine, Faculty of Health Sciences, University of Surrey, Guildford, UK

    L. G. Forni

Authors
  1. S. M. T. Nasser
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  2. N. Boyer
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  3. L. G. Forni
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Correspondence to L. G. Forni .

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Editors and Affiliations

  1. Department of Intensive Care, Erasme University Hospital Université libre de Bruxelles, Brussels, Belgium

    Jean-Louis Vincent

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Nasser, S.M.T., Boyer, N., Forni, L.G. (2022). Hemodynamic Instability During Continuous Renal Replacement Therapy: Is It All About Fluid?. In: Vincent, JL. (eds) Annual Update in Intensive Care and Emergency Medicine 2022. Annual Update in Intensive Care and Emergency Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-93433-0_16

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  • DOI: https://doi.org/10.1007/978-3-030-93433-0_16

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  • Online ISBN: 978-3-030-93433-0

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