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Mechanisms for hemodynamic instability related to renal replacement therapy: a narrative review

Published on Oct 1, 2019in Intensive Care Medicine18.967
· DOI :10.1007/s00134-019-05707-w
Adrianna Douvris2
Estimated H-index: 2
(U of O: University of Ottawa),
Khalid Zeid1
Estimated H-index: 1
(U of O: University of Ottawa)
+ 6 AuthorsEdward G. Clark12
Estimated H-index: 12
(U of O: University of Ottawa)
Abstract
Hemodynamic instability related to renal replacement therapy (HIRRT) is a frequent complication of all renal replacement therapy (RRT) modalities commonly used in the intensive care unit. HIRRT is associated with increased mortality and may impair kidney recovery. Our current understanding of the physiologic basis for HIRRT comes primarily from studies of end-stage kidney disease patients on maintenance hemodialysis in whom HIRRT is referred to as ‘intradialytic hypotension’. Nonetheless, there are many studies that provide additional insights into the underlying mechanisms for HIRRT specifically in critically ill patients. In particular, recent evidence challenges the notion that HIRRT is almost entirely related to excessive ultrafiltration. Although excessive ultrafiltration is a key mechanism, multiple other RRT-related mechanisms may precipitate HIRRT and this could have implications for how HIRRT should be managed (e.g., the appropriate response might not always be to reduce ultrafiltration, particularly in the context of significant fluid overload). This review briefly summarizes the incidence and adverse effects of HIRRT and reviews what is currently known regarding the mechanisms underpinning it. This includes consideration of the evidence that exists for various RRT-related interventions to prevent or limit HIRRT. An enhanced understanding of the mechanisms that underlie HIRRT, beyond just excessive ultrafiltration, may lead to more effective RRT-related interventions to mitigate its occurrence and consequences.
  • References (83)
  • Citations (2)
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References83
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#2Sreelatha KatariH-Index: 1
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OBJECTIVES:Acute kidney injury requiring renal replacement therapy is associated with high morbidity and mortality. Complications of renal replacement therapy include hemodynamic instability with ensuing shortened treatments, inadequate ultrafiltration, and delay in renal recovery. Studies have shown that lowering dialysate temperature in patients with end-stage renal disease is associated with a decrease in the frequency of intradialytic hypotension. However, data regarding mitigation of hypote...
1 CitationsSource
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#2Vikram Balakumar (University of Pittsburgh)H-Index: 3
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Background Although net ultrafiltration (UFNET) is frequently used for treatment of fluid overload in critically ill patients with acute kidney injury, the optimal intensity of UFNET is unclear. Among critically ill patients with fluid overload receiving renal replacement therapy (RRT), we examined the association between UFNET intensity and risk-adjusted 1-year mortality.
7 CitationsSource
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2 CitationsSource
#1Adrianna Douvris (U of O: University of Ottawa)H-Index: 2
#2Gurpreet Malhi (U of O: University of Ottawa)H-Index: 1
Last. Edward G. Clark (Ottawa Hospital Research Institute)H-Index: 12
view all 11 authors...
Background Hemodynamic instability related to renal replacement therapy (HIRRT) may increase the risk of death and limit renal recovery. Studies in end-stage renal disease populations on maintenance hemodialysis suggest that some renal replacement therapy (RRT)-related interventions (e.g., cool dialysate) may reduce the occurrence of HIRRT, but less is known about interventions to prevent HIRRT in critically ill patients receiving RRT for acute kidney injury (AKI). We sought to evaluate the effe...
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The risk of intradialytic hypotension (IDH) is determined by various factors, among them dialysis modality and dialyzer membrane. We conducted a literature search in PubMed on November 1, 2016 and selected relevant randomized controlled and cross-over trials, and prospective and retrospective cohort studies published in English that investigated the association between IDH and dialysis modality and membrane, respectively. This literature search revealed 669 publications on dialysis modality, 64 ...
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Abnormal decreases in blood pressure during hemodialysis are frequent in end stage renal disease (ESRD) patients treated with hemodialysis, and thought to be largely due to an inadequate cardiovascular response to the rapid blood volume decline. Intradialytic hypotension (IDH) and cardiac instability during dialysis can increase risks for negative health consequences and is possibly preventable though several types of interventions. One intervention that holds promise for prevention of IDH in he...
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#2Sushrut S. Waikar (Brigham and Women's Hospital)H-Index: 43
The treatment of severe acute kidney injury (AKI) with dialytic support for renal replacement therapy can be life sustaining and permit recovery from critical illness. Like any interventional therapy, however, renal replacement therapy with intermittent hemodialysis or continuous therapy can cause complications. Intradialytic hypotension is a common complication and can cause further ischemic injury to the recovering kidneys, thereby reducing the probability of renal recovery. The optimal dialyt...
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Intradialytic hypotension, a complication of intermittent hemodialysis, decreases the efficacy of dialysis and increases long-term mortality. This study was aimed to determine whether different predialysis ultrasound cardiopulmonary profiles could predict intradialytic hypotension. This prospective observational single-center study was performed in 248 critically ill patients with acute kidney injury undergoing intermittent hemodialysis. Immediately before hemodialysis, vena cava collapsibility ...
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