Dynamics of Plasma Refill Rate and Intradialytic Hypotension During Hemodialysis: Retrospective Cohort Study With Causal Methodology.
Dynamics of Plasma Refill Rate and Intradialytic Hypotension During Hemodialysis: Retrospective Cohort Study With Causal Methodology.
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DOI：
10.34067/kid.0000000000000082
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发表时间：
2023-04-01
期刊：
影响因子：
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通讯作者：
Dember LM
中科院分区：
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作者：
Wang CH;Negoianu D;Zhang H;Casper S;Hsu JY;Kotanko P;Raimann J;Dember LM
直接研究血液透析（HD）过程中的血浆再充盈率（PRR）可以深入了解整个HD过程中发生变化的生理机制。开始时和HD期间的PRR与透析中低血压相关，与超滤率无关。HD期间PRR升高可能是即将发生的循环不稳定的代偿机制的早期指标。对于接受维持性血液透析（HD）的患者而言，在实现足够的容量清除同时保持器官灌注之间达到最佳平衡是一项挑战。目前指导超滤的策略是不够的。我们开发了一种方法，使用2017年1月至2019年10月期间在17个透析单位接受维持性HD的患者回顾性队列中的红细胞压积和超滤数据计算整个HD期间的血浆再充盈率（PRR）。我们研究了（1）PRR是否与使用逻辑回归的血流动力学不稳定的传统风险因素相关，（2）低起始PRR是否与使用考克斯比例风险回归的透析中低血压（IDH）相关，以及（3）使用边际结构模型的整个HD期间随时间变化的PRR是否与低血压相关。在2554例患者的180，319次HD治疗期间，PRR具有较高的患者内和患者间变异性。女性和低白蛋白血症与HD第一小时内多个时间点的低PRR相关。低起始PRR具有较高的IDH风险，而高起始PRR具有保护作用（风险比[HR]，1.26，95%置信区间[CI]，1.18 - 1.35 vs HR，0.79，95% CI，0.73 - 0.85）。然而，当考虑时变PRR和时变混杂因素时，与中度PRR相比，持续低PRR与低血压风险增加相关。（比值比[OR]，1.09，95%CI，1.02至1.16），持续高PRR与接下来15分钟内的低血压有更强的相关性（OR，1.38，95% CI，1.30 - 1.45）。我们提出了一种简单的技术来量化血浆再灌注，可以很容易地集成到设备，监测血细胞比容在HD。我们的研究强调了检查血浆再充盈模式如何增强我们对HD期间循环变化的理解，这是了解当前技术如何用于改善血流动力学不稳定性的重要一步。
Directly studying plasma refill rate (PRR) during hemodialysis (HD) can offer insight into physiologic mechanisms that change throughout HD. PRR at the start and during HD is associated with intradialytic hypotension, independent of ultrafiltration rate. A rising PRR during HD may be an early indicator of compensatory mechanisms for impending circulatory instability. Attaining the optimal balance between achieving adequate volume removal while preserving organ perfusion is a challenge for patients receiving maintenance hemodialysis (HD). Current strategies to guide ultrafiltration are inadequate. We developed an approach to calculate the plasma refill rate (PRR) throughout HD using hematocrit and ultrafiltration data in a retrospective cohort of patients receiving maintenance HD at 17 dialysis units from January 2017 to October 2019. We studied whether (1) PRR is associated with traditional risk factors for hemodynamic instability using logistic regression, (2) low starting PRR is associated with intradialytic hypotension (IDH) using Cox proportional hazard regression, and (3) time-varying PRR throughout HD is associated with hypotension using marginal structural modeling. During 180,319 HD sessions among 2554 patients, PRR had high within-patient and between-patient variability. Female sex and hypoalbuminemia were associated with low PRR at multiple time points during the first hour of HD. Low starting PRR has a higher hazard of IDH, whereas high starting PRR was protective (hazard ratio [HR], 1.26, 95% confidence interval [CI], 1.18 to 1.35 versus HR, 0.79, 95% CI, 0.73 to 0.85, respectively). However, when accounting for time-varying PRR and time-varying confounders, compared with a moderate PRR, while a consistently low PRR was associated with increased risk of hypotension (odds ratio [OR], 1.09, 95% CI, 1.02 to 1.16), a consistently high PRR had a stronger association with hypotension within the next 15 minutes (OR, 1.38, 95% CI, 1.30 to 1.45). We present a straightforward technique to quantify plasma refill that could easily integrate with devices that monitor hematocrit during HD. Our study highlights how examining patterns of plasma refill may enhance our understanding of circulatory changes during HD, an important step to understand how current technology might be used to improve hemodynamic instability.