Jongejan Micha, Gelinck Armin, van Geloven Nan, Dekker Friedo W, Vleming Louis Jean
Department of Nephrology, HagaZiekenhuis, The Hague, The Netherlands.
Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands.
Clin Kidney J. 2024 Apr 25;17(5):sfae128. doi: 10.1093/ckj/sfae128. eCollection 2024 May.
Ultrafiltration to target weight during haemodialysis is complicated by intradialytic hypotension-associated adverse events (IHAAEs) in 10-30% of dialysis treatments. IHAAEs are caused by critical reductions in absolute blood volume (ABV), due to the interaction of ultrafiltration, refill and compensatory mechanisms. Non-randomised studies have suggested that ABV-guided treatment, using an indicator dilution technique employing the blood volume monitor on the dialysis machine, could reduce the incidence of IHAAEs.
We performed an open-label randomised controlled trial. Patients were randomly assigned to adjustment of target weight guided by ABV measurements or standard care. The primary outcome was the change in the incidence of IHAAEs from baseline, defined as the percentage of treatment episodes in a 4-week period where the patient had a systolic blood pressure <90 mmHg or symptoms of impending hypotension. ABV measurements were compared with anthropomorphometric estimation and the gold standard using isotope dilution.
A total of 56 patients were randomised, of whom 29 were allocated to ABV-guided treatment and 27 to standard care. Overall baseline incidence of IHAAEs was 26.0%. ABV-guided treatment significantly reduced the incidence of IHAAEs compared with standard care, with a mean change from baseline of -9.6% [95% confidence interval (CI) -17.3 to -1.8) versus 2.4% (95% CI -2.3-7.2). The adjusted difference between the groups was 10.5% (95% CI 1.3-19.8; = .026). ABV measurement had moderate agreement with other methods to estimate blood volume. The sensitivity for the previously suggested threshold of a post-dialysis normalised blood volume of 65 ml/kg was observed to be 74% in this study.
ABV-guided volume management significantly reduced IHAAEs compared with standard care. The clinical relevance of the previously suggested threshold of 65 ml/kg cannot be firmly concluded on the basis of our results. If confirmed in a larger trial, this intervention could potentially change dialysis practice and impact patient care in a clinically meaningful way.
血液透析期间以目标体重进行超滤会因透析中低血压相关不良事件（IHAAEs）而变得复杂，在10%至30%的透析治疗中会出现此类情况。IHAAEs是由超滤、补液和代偿机制相互作用导致的绝对血容量（ABV）严重减少引起的。非随机研究表明，使用透析机上的血容量监测器采用指示剂稀释技术进行ABV指导的治疗，可降低IHAAEs的发生率。
我们进行了一项开放标签随机对照试验。患者被随机分配至由ABV测量指导的目标体重调整组或标准治疗组。主要结局是IHAAEs发生率相对于基线的变化，定义为患者收缩压<90 mmHg或有即将发生低血压症状的4周内治疗发作的百分比。将ABV测量结果与人体测量估计值以及使用同位素稀释的金标准进行比较。
共有56例患者被随机分组，其中29例被分配至ABV指导的治疗组，27例被分配至标准治疗组。IHAAEs的总体基线发生率为26.0%。与标准治疗相比，ABV指导的治疗显著降低了IHAAEs的发生率，相对于基线的平均变化为-9.6%[95%置信区间（CI）-17.3至-1.8]，而标准治疗组为2.4%（95% CI -2.3至7.2）。两组之间的调整差异为1（95% CI 1.3至19.8；P = 0.026）。ABV测量与其他估计血容量的方法具有中等一致性。在本研究中，观察到先前建议的透析后标准化血容量阈值65 ml/kg的敏感性为74%。
与标准治疗相比，ABV指导的容量管理显著降低了IHAAEs。根据我们的结果，无法确凿得出先前建议的65 ml/kg阈值的临床相关性。如果在更大规模试验中得到证实，这种干预可能会改变透析实践，并以具有临床意义的方式影响患者护理。
