New instrumental options for optimizing the hemodialysis program
V.Yu. Shilo, I.Yu. Drachev
1) A.I. Yevdokimov Moscow State University of Medicine and Dentistry; Moscow, Russia
2) Tver State Medical University; Tver, Russia
3) B. Braun Avitum Russland Kliniks; Moscow, Russia
Background. The modern concept of the adequacy of dialysis from the perspective of a doctor implies primarily the adequacy of the removal of toxins, water balance and nutrition. In recent years, however, the outcome of treatment from the position of the patient, in particular the tolerability of the dialysis procedure itself, has been increasingly important. In this regard, new instrumental methods for monitoring the achievement of the dialysis dose and the prevention of complications of the dialysis procedure, which allow to find a balance between the achievement of treatment targets and the satisfactory tolerance of the hemodialysis (HD) procedure are of great interest.
Objective. To evaluate the possibilities of new instrumental options – on-line-measurements of the provided dialysis dose using ultraviolet spectrophotometry of the spent dialysate in achieving an adequate dose of the dialysis session and the computer algorithm for ultrafiltration (UF) rate control for the prevention of intradialytic hypotension.
Material and methods. The work included data from a single-center study enrolling of 135 patients with an established diagnosis of chronic kidney disease-5D at the B. Brown Avitum dialysis center in Moscow. In order to solve the tasks set in the work, two clinical trials were conducted; the first included 100 patients and evaluated the comparative effectiveness of various methods of measuring the provided hemodialysis dose over a calendar year. The eKt/V index data was recorded using the Adimea on-line dialysis dose monitoring unit and calculated on the basis of laboratory blood samples before and after the HD procedure using the second generation Daugirdas’ formula as the reference method. The second study included 35 patients with a tendency to intradialytic hypotension (IDH) and evaluated the feasibility of a new method for UF rate control using the module of an automatic blood pressure control (ABPC) system to prevent symptomatic episodes of IDH.
Results. The mean UV-eKt/V values obtained by the ultraviolet spectrophotometry of spent dialysate did not significantly differ from the eKt/V calculated by the Daugirdas’ formula using the reference method of laboratory samples (1.65±0.26 and 1.64±0.24; p=0.93), while a strong correlation between the results obtained by both methods (r=0.8, p=0.000) was consistently revealed.
The advantages of the method of on-line monitoring of spent dialysate include the elimination of errors when taking blood samples by medical personnel, the lower variability of the eKT/V index, and the ability to timely detect a decrease in the dialysis dose, establish its causes and make adjustments to the hemodialysis program. Using a new approach to the prevention and correction of IDH with a computer-based UV rate control algorithm, reliable data were obtained – the average values of pre- and post-dialysis systolic blood pressure (SBP) and diastolic blood pressure (DBP) were higher when using the ABPC module. The pre-dialysis SBP and DBP levels were 132.5±25 and 78.6±18.1 versus 124.3±26.6 and 73.7±18.1 mm Hg (p=0.009 and p=0.0008, respectively). The postdialysis blood pressure levels differed: when using ABPC module, the average blood pressure levels were higher than with the standard approach. The postdialysis SBP and DBP levels were 125.7±24 and 75.9±18.3 versus 114.3±24.4 and 71.2±16.3 mm Hg (p=0.002 and p=0.006, respectively). When using ABPC system, the intradialytic blood pressure variations were higher: SBP 124.0±20.5 versus 110.2±17.3 (p=0.03) and DBP 75.9±14.2 versus 68.3±17.9 mm Hg (p=0.02) Thus, the use of a UF control system led to an increase in intradialysis SBP by 11.1%, DBP by 10%, and MAP by 9.83%. The number of interventions of a 40% glucose solution (10.0) decreased by 54.5% – from 86 to 27 (p=0,000). The results of our study showed that the prevalence of hypotension episodes when applying the conservative approach without computer UF rate control was 26.2% (211 cases per 1134 blood pressure measurements), while when using the ABPC module, the frequency of hypotension significantly decreased and was 8.3% (387 cases per 4972 blood pressure measurements). The percentage reduction was 20.33% (p=0,000). Thus, the obtained results allow to conclude that instrumental method for UF rate control is effective in the prevention of symptomatic IDH episodes associated with high UF rates.
Conclusion. On-line monitoring of the dialysis dose is the preferred method for estimating the eKt/V index due to a number of advantages compared to the classical method for evaluating laboratory blood samples: it eliminates errors during blood sampling by personnel, monitoring of the eKt/V index lasts throughout procedure, the dialysis dose is determined at each hemodialysis session, which allows timely adjustments to the dialysis program. The use of a computer algorithm for UF rate control contributes to the optimization and personification of the hemodialysis program, making it possible to reduce the number of IDH episodes and reduce the frequency of interventions during the procedure. Continuous monitoring of the patient’s controlled parameters during the HD procedure and the “feedback” option reduces the risk of complications and improves the quality of treatment as a whole.
About the Autors
Valery Yu. Shilo – PhD in Medical Sciences, Associate Professor at the Department of Nephrology, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Medical Director of the Network of Dialysis Clinics of LLC “B. Braun Avitum Russland” in the Russian Federation; Moscow, Russia. E-mail: email@example.com, ORCID: 0000-0001-9025-8061
Ivan Yu.Drachev – Postgraduate Student at the Department of Internal Diseases, Tver State Medical University, Nephrologist at the LLC B. Brown Avitum Moscow Dialysis Center
(MCHTP № 1); Tver, Russia. E-mail: firstname.lastname@example.org, ORCID: 0000-0001-9911-3889