Canaud Bernard, Chazot Charles, Koomans Jeroen, Collins Allan
Montpellier University, Montpellier, France.
Senior Medical Scientist, Global Medical Office, FMC Deutschland, Bad Homburg, Germany.
J Bras Nefrol. 2019 Oct-Dec;41(4):550-559. doi: 10.1590/2175-8239-JBN-2019-0135.
Fluid volume and hemodynamic management in hemodialysis patients is an essential component of dialysis adequacy. Restoring salt and water homeostasis in hemodialysis patients has been a permanent quest by nephrologists summarized by the 'dry weight' probing approach. Although this clinical approach has been associated with benefits on cardiovascular outcome, it is now challenged by recent studies showing that intensity or aggressiveness to remove fluid during intermittent dialysis is associated with cardiovascular stress and potential organ damage. A more precise approach is required to improve cardiovascular outcome in this high-risk population. Fluid status assessment and monitoring rely on four components: clinical assessment, non-invasive instrumental tools (e.g., US, bioimpedance, blood volume monitoring), cardiac biomarkers (e.g. natriuretic peptides), and algorithm and sodium modeling to estimate mass transfer. Optimal management of fluid and sodium imbalance in dialysis patients consist in adjusting salt and fluid removal by dialysis (ultrafiltration, dialysate sodium) and by restricting salt intake and fluid gain between dialysis sessions. Modern technology using biosensors and feedback control tools embarked on dialysis machine, with sophisticated analytics will provide direct handling of sodium and water in a more precise and personalized way. It is envisaged in the near future that these tools will support physician decision making with high potential of improving cardiovascular outcome.
血液透析患者的液体容量和血流动力学管理是透析充分性的重要组成部分。恢复血液透析患者的盐和水平衡一直是肾脏病学家通过“干体重”探索方法所追求的目标。尽管这种临床方法已被证明对心血管结局有益，但最近的研究对其提出了挑战，这些研究表明，间歇性透析期间去除液体的强度或激进程度与心血管应激和潜在器官损伤有关。需要一种更精确的方法来改善这一高危人群的心血管结局。液体状态评估和监测依赖于四个方面：临床评估、非侵入性仪器工具（如超声、生物阻抗、血容量监测）、心脏生物标志物（如利钠肽）以及用于估计质量传递的算法和钠模型。透析患者液体和钠失衡的最佳管理包括通过透析（超滤、透析液钠）以及限制透析期间的盐摄入和液体摄入来调整盐和液体的去除。使用生物传感器和反馈控制工具的现代技术应用于透析机，并通过复杂的分析，将以更精确和个性化的方式直接处理钠和水。预计在不久的将来，这些工具将支持医生决策，具有改善心血管结局的巨大潜力。
