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      Association between intradialytic central venous oxygen saturation and ultrafiltration volume in chronic hemodialysis patients

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          Abstract

          Background

          Cardiac disease is highly prevalent in hemodialysis (HD) patients. Decreased tissue perfusion, including cardiac, due to high ultrafiltration volumes (UFVs) is considered to be one of the drivers of cardiac dysfunction. While central venous oxygen saturation (ScvO 2) is frequently used as an indicator of cardiac output in non-uremic populations, the relationship of ScvO 2 and UFV in HD patients remains unclear. Our aim was to determine how intradialytic ScvO 2 changes associate with UFV.

          Methods

          We conducted a 6-month retrospective cohort study in maintenance HD patients with central venous catheters as vascular access. Intradialytic ScvO 2 was measured with the Critline monitor. We computed treatment-level slopes of intradialytic ScvO 2 over time (ScvO 2 trend) and applied linear mixed effects models to assess the association between patient-level ScvO 2 trends and UFV corrected for body weight (cUFV).

          Results

          We studied 6042 dialysis sessions in 232 patients. In about 62.4% of treatments, ScvO 2 decreased. We observed in nearly 80% of patients an inverse relationship between cUFV and ScvO 2 trend, indicating that higher cUFV is associated with steeper decline in ScvO 2 during dialysis.

          Conclusions

          In most patients, higher cUFV volumes are associated with steeper intradialytic ScvO 2 drops. We hypothesize that in a majority of patients the intradialytic cardiac function is fluid dependent, so that in the face of high ultrafiltration rates or volume, cardiac pre-load and consequently cardiac output decreases. Direct measurements of cardiac hemodynamics are warranted to further test this hypothesis.

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          Hemodialysis-induced cardiac injury: determinants and associated outcomes.

          James O. Burton, Helen Jefferies, Nicholas M. Selby … (2009)
          Hemodialysis (HD)-induced myocardial stunning driven by ischemia is a recognized complication of HD, which can be ameliorated by HD techniques that improve hemodynamics. In nondialysis patients, repeated ischemia leads to chronic reduction in left ventricular (LV) function. HD may initiate and drive the same process. In this study, we examined the prevalence and associations of HD-induced repetitive myocardial injury and long-term effects on LV function and patient outcomes. Seventy prevalent HD patients were assessed for evidence of subclinical myocardial injury at baseline using serial echocardiography and followed up after 12 mo. Intradialytic blood pressure, hematologic and biochemical samples, and patient demographics were also collected at both time points. Sixty-four percent of patients had significant myocardial stunning during HD. Age, ultrafiltration volumes, intradialytic hypotension, and cardiac troponin-T (cTnT) levels were independent determinants associated with its presence. Myocardial stunning was associated with increased relative mortality at 12 mo (P = 0.019). Cox regression analysis showed increased hazard of death in patients with myocardial stunning and elevated cTnT than in patients with elevated cTnT alone (P < 0.02). Patients with myocardial stunning who survived 12 mo had significantly lower LV ejection fractions at rest and on HD (P < 0.001). HD-induced myocardial stunning is common, and may contribute to the development of heart failure and increased mortality in HD patients. Enhanced understanding of dialysis-induced cardiac injury may provide novel therapeutic targets to reduce currently excessive rates of cardiovascular morbidity and mortality.
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            Predictors of early mortality among incident US hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS).

            Cathy Critchlow, Jon S Anthony, Ronald L. Pisoni … (2006)
            Mortality risk among hemodialysis (HD) patients may be highest soon after initiation of HD. A period of elevated mortality risk was identified among US incident HD patients, and which patient characteristics predict death during this period and throughout the first year was examined using data from the Dialysis Outcomes and Practice Patterns Study (DOPPS; 1996 through 2004). A retrospective cohort study design was used to identify mortality risk factors. All patient information was collected at enrollment. Life-table analyses and discrete logistic regression were used to identify a period of elevated mortality risk. Cox regression was used to estimate adjusted hazard ratios (HR) measuring associations between patient characteristics and mortality and to examine whether these associations changed during the first year of HD. Among 4802 incident patients, risk for death was elevated during the first 120 d compared with 121 to 365 d (27.5 versus 21.9 deaths per 100 person-years; P = 0.002). Cause-specific mortality rates were higher in the first 120 d than in the subsequent 121 to 365 d for nearly all causes, with the greatest difference being for cardiovascular-related deaths. In addition, 20% of all deaths in the first 120 d occurred subsequent to withdrawal from dialysis. Most covariates were found to have consistent effects during the first year of HD: Older age, catheter vascular access, albumin <3.5, phosphorus <3.5, cancer, and congestive heart failure all were associated with elevated mortality. Pre-ESRD nephrology care was associated with a significantly lower risk for death before 120 d (HR 0.65; 95% confidence interval 0.51 to 0.83) but not in the subsequent 121- to 365-d period (HR 1.03; 95% confidence interval 0.83 to 1.27). This care was related to approximately 50% lower rates of both cardiac deaths and withdrawal from dialysis during the first 120 d. Mortality risk was highest in the first 120 d after HD initiation. Inadequate predialysis nephrology care was strongly associated with mortality during this period, highlighting the potential benefits of contact with a nephrologist at least 1 mo before HD initiation.
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              Association of mortality risk with various definitions of intradialytic hypotension.

              Jennifer E. Flythe, Hui Xue, Katherine E Lynch … (2015)
              Intradialytic hypotension is a serious and frequent complication of hemodialysis; however, there is no evidence-based consensus definition of intradialytic hypotension. As a result, coherent evaluation of the effects of intradialytic hypotension is difficult. We analyzed data from 1409 patients in the HEMO Study and 10,392 patients from a single large dialysis organization to investigate the associations of commonly used intradialytic hypotension definitions and mortality. Intradialytic hypotension definitions were selected a priori on the basis of literature review. For each definition, patients were characterized as having intradialytic hypotension if they met the corresponding definition in at least 30% of baseline exposure period treatments or characterized as control otherwise. Overall and within subgroups of patients with predialysis systolic BP<120 or 120-159 mmHg, an absolute nadir systolic BP<90 mmHg was most potently associated with mortality. Within the subgroup of patients with predialysis BP≥160 mmHg, nadir BP<100 mmHg was most potently associated with mortality. Intradialytic hypotension definitions that considered symptoms, interventions, and decreases in BP during dialysis were not associated with outcome, and when added to nadir BP, symptom and intervention criteria did not accentuate associations with mortality. Our results suggest that nadir-based definitions best capture the association between intradialytic hypotension and mortality.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Nephrol Dial Transplant
                Journal ID (iso-abbrev): Nephrol. Dial. Transplant
                Journal ID (publisher-id): ndt
                Title: Nephrology Dialysis Transplantation
                Publisher: Oxford University Press
                ISSN (Print): 0931-0509
                ISSN (Electronic): 1460-2385
                Publication date (Print): September 2018
                Publication date (Electronic): 12 September 2017
                Publication date PMC-release: 12 September 2017
                Volume: 33
                Issue: 9
                Pages: 1636-1642
                Affiliations
                [1 ]Renal Research Institute, New York, NY, USA
                [2 ]Department of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
                [3 ]Department of Internal Medicine Maastricht University Medical Centre, Maastricht, The Netherlands
                Author notes
                Correspondence and offprint requests to: Peter Kotanko; E-mail: pkotanko@ 123456rriny.com
                Article
                Publisher ID: gfx271
                DOI: 10.1093/ndt/gfx271
                PMC ID: 6113642
                PubMed ID: 28927232
                SO-VID: f4170a90-7503-44a8-bc3d-495d2377c051
                Copyright © © The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                History
                Date received : 22 March 2017
                Date accepted : 31 July 2017
                Page count
                Pages: 7
                Funding
                Funded by: NIH 10.13039/100000002
                Award ID: 5T32DK007757 - 18
                Categories
                Subject: Original Articles
                Subject: Dialysis

                ScienceOpen disciplines: Nephrology
                Keywords: central venous oxygen saturation,hemodialysis,hypoxia,pre-load,ultrafiltration
                Data availability:
                ScienceOpen disciplines: Nephrology
                Keywords: central venous oxygen saturation, hemodialysis, hypoxia, pre-load, ultrafiltration

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