Accuracy and precision of access recirculation measurements by the hemodynamic recirculation monitor.

The hemodynamic monitor (HDM) is a device that uses magnetic principles to accurately measure access recirculation during hemodialysis. The measurement is based on differential conductivity between arterial and venous blood flow rates in the dialysis blood tubing sets. One milliliter of hypertonic saline is injected into the venous line of the blood tubing set as a conductivity "tracer." As the tracer enters the patient, the presence of access recirculation causes a percentage of the hypertonic saline to recirculate into the arterial line and is detected and quantified by the HDM; the percentage of access recirculation is calculated in under 1 minute. Clinical studies were performed in two centers on 106 patients with various forms of blood access (eg, arteriovenous fistulae, Gore-tex grafts [WL Gore and Associates, Flagstaff, AZ], Permcaths [Quinton Instrument Co, Bothell, WA], subclavian catheters). Access recirculation was detected under routine dialysis conditions in only 13 patients. In the remaining cases, attempts at inducing access recirculation were made by reversing the arterial and venous lines and/or increasing the blood pump to its maximum sustainable rate for a given patient. A 15-minute protocol was then instituted. Three blood samples (arterial, venous, and "peripheral" [stop-flow technique]) were first obtained to determine urea measurements and for subsequent calculation of access recirculation; immediately afterward, an HDM recirculation measurement was recorded to allow correlation of urea and HDM access recirculation results (accuracy). Two further HDM access recirculation measurements were made to analyze the precision or repeatability of the HDM test. This protocol was attempted up to three times in each patient on different dialysis days. Two hundred fifty-nine studies were made, and a strong linear correlation was obtained between urea and HDM results (r = 0.94, slope 0.95) over a range of access recirculation (5% to 60%) demonstrating accuracy. Repeated HDM access recirculation results showed a characteristic SD of 1.8% over the whole range of values, demonstrating a precision superior to the 6% expected using the urea method. When zero access recirculation was indicated by the HDM, "ground truth" tests were performed by injecting 1 mL of hypertonic saline (HS) into one injection port of the blood tubing set then 0.1 mL of HS into the other to simulate 10% access recirculation; the mean results were 9.96%+/-1.59% (+/-SD; n = 93), confirming the accuracy of the method.