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      Rationale for the Use of Blood Volume and Temperature Control Devices during Hemodialysis

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          Abstract

          Despite substantial progress in blood purification techniques over the last three decades, treatment-related hypotensive episodes remain one of the major problems in hemodialysis therapy. There are two main reasons for hypotension occurring during dialysis treatments. First, hypovolemia is frequently induced by rapid fluid removal from the blood compartment which is in excess of refilling of fluids from the interstitial space. Second, many patients fail to support blood pressure by adequate vasoconstriction or increased heart rate as a response to hypovolemia. The capacity to respond adequately to volume contraction may be reduced due to patient- or treatment-related factors, among which heat accumulation within the body plays a major role. Recently, two newer technical developments became commercially available for use in hemodialysis therapy: devices for blood volume and blood temperature control were designed to reduce the incidence of intradialytic hypotension. Although blood volume and temperature measurements are easy to perform today, there is some uncertainty in the dialysis community how and when their use may be helpful and in which patients it is indicated. This review critically discusses the application of blood volume- and temperature-measuring devices with regard to their usefulness in the clinical setting.

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          Most cited references 6

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          Blood volume controlled hemodialysis in hypotension-prone patients: a randomized, multicenter controlled trial.

          Recently we have devised and tested a biofeedback system for controlling blood volume (BV) changes during hemodialysis (HD) along an ideal trajectory (blood volume tracking, BVT), continuously modifying the weight loss rate and dialysate conductivity. This multicenter, prospective, randomized, crossover study aimed to clarify whether BVT (treatment B) can improve hypotension-prone patients' treatment tolerance, compared with conventional hemodialysis (treatment A). Thirty-six hypotension-prone patients enrolled from 10 hemodialysis (HD) centers were randomly assigned to either of the study sequences ABAB or BABA, each lasting four months. A 30% reduction in intradialytic hypotension (IDH) events was observed in treatment B as compared with A (23.5% vs. 33.5%, P = 0.004). The reduction was related to the number of IDH in treatment A (y = 0.54x + 5; r = 0.4; P < 0.001): the more IDH episodes in treatment A, the better the response in treatment B. The best responders to treatment B showed pre-dialysis systolic blood pressure values higher than the poor responders (P = 0.04). A 10% overall reduction in inter-dialysis symptoms was obtained also in treatment B compared to A (P < 0.001). Body weight gain, pre-dialysis blood pressure, intradialytic weight loss as well as Kt/V did not differ between the two treatments. An overall improvement in the treatment tolerance was observed with BVT, particularly intradialytic cardiovascular stability. Patients with the highest incidence of IDH during conventional HD and free from chronic pre-dialysis hypotension seem to respond better. Inter-dialysis symptoms also seem to improve with control of BV.
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            The effects of control of thermal balance on vascular stability in hemodialysis patients: results of the European randomized clinical trial.

            Many reports note that the use of cool dialysate has a protective effect on blood pressure during hemodialysis (HD) treatments. However, formal clinical trials in which dialysate temperature is tailored to the body temperature of appropriately selected hypotension-prone patients are lacking. We investigated the effect of thermal control of dialysate on hemodynamic stability in hypotension-prone patients selected from 27 centers in nine European countries. Patients were eligible for the study if they had symptomatic hypotensive episodes in 25% or more of their HD sessions, assessed during a prospective screening phase over 1 month. The study is designed as a randomized crossover trial with two phases and two treatment arms, each phase lasting 4 weeks. We used a device allowing the regulation of thermal balance (Blood Temperature Monitor; Fresenius Medical Care, Bad Homberg, Germany), by which we compared a procedure aimed at preventing any transfer of thermal energy between dialysate and extracorporeal blood (thermoneutral dialysis) with a procedure aimed at keeping body temperature unchanged (isothermic dialysis). One hundred sixteen HD patients were enrolled, and 95 patients completed the study. During thermoneutral dialysis (energy flow rate: DeltaE = -0.22 +/- 0.29 kJ/kg x h), 6 of 12 treatments (median) were complicated by hypotension, whereas during isothermic dialysis (energy flow rate: DeltaE = -0.90 +/- 0.35 kJ/kg x h), the median decreased to 3 of 12 treatments (P < 0.001). Systolic and diastolic blood pressures and heart rate were more stable during the latter procedure. Isothermic dialysis was well tolerated by patients. Results show that active control of body temperature can significantly improve intradialytic tolerance in hypotension-prone patients. Copyright 2002 by the National Kidney Foundation, Inc.
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              Intradialytic Hypotension: An Overview of Recent, Unresolved and Overlooked Issues

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                Author and article information

                Journal
                KBR
                Kidney Blood Press Res
                10.1159/issn.1420-4096
                Kidney and Blood Pressure Research
                S. Karger AG
                978-3-8055-7600-0
                978-3-318-00991-0
                1420-4096
                1423-0143
                2003
                2003
                05 June 2003
                : 26
                : 2
                : 82-89
                Affiliations
                aDepartment of Nephrology, University Hospital Freiburg and bDeutsche Klinik für Diagnostik, Division of Nephrology, Wiesbaden, Germany
                Article
                70988 Kidney Blood Press Res 2003;26:82–89
                10.1159/000070988
                12771531
                © 2003 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 2, References: 76, Pages: 8
                Product
                Self URI (application/pdf): https://www.karger.com/Article/Pdf/70988
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