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Parker TF, 3rd, Hakim R, Nissenson AR, et al. A quality initiative. Reducing rates of hospitalizations by objectively monitoring volume removal. Nephrol News Issues. Mar 2013;27(3):30-2, 34-36.
,S1 These studies have employed RBVM predominantly with goals to improve blood pressure control and ensure adequate volume removal but data are conflicting. Some studies have shown that RBVM improves blood pressure and decreases hospitalizations5,6, whereas others have shown no improvement in IDH and potential worsening of hospitalizations among ESKD patients.7Reddan D.N. Szczech L.A. Hasselblad V. et al.Intradialytic blood volume monitoring in ambulatory hemodialysis patients: a randomized trial. Data on the use of RBVM in the acute hospital setting is scarce.We performed a prospective quality improvement study to examine the hypothesis that using RBVM during acute hemodialysis sessions for hospitalized patients with AKI requiring RRT and ESKD would reduce IDH.
Methods:Full methods are given in the Supplemental information. Briefly, we performed a time series study in all hospitalized adult AKI and ESKD patients undergoing acute hemodialysis at the University of Colorado Hospital. The control and intervention periods were 3 months in length. After the control period, there was 1-month run-in period used for training the nurses to use the RBVM device, Crit-Line. During the intervention period, RBVM was used for all patients undergoing dialysis and nurses actively monitored and adjusted treatments according to blood volume profiles. The study protocol was approved by the Colorado Multiple Institutional Review Board (Aurora, CO).
The primary outcome was number of IDH events, defined by the NKF KDOQI Guidelines as a fall in systolic blood pressure by ≥20mmHg or a fall in mean arterial pressure by ≥10mmHg with associated symptoms.8/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients.Results:A total of 328 patients were included in this study, 161 from the control period and 167 from the intervention period. Patient characteristics were similar in both time periods (Table 1). We examined data from 357 acute dialysis treatments in the control period and 321 acute dialysis treatments in the intervention period. IDH occurred during 23.5% of all dialysis treatments during the control period and 18.7% during the intervention period, but the difference was not significant, OR 0.75 (0.47-1.1), p=0.22 (Table 2). There were no significant differences in modifications made to the dialysis treatments or patient symptoms (Table 2). There was no difference in UF rate between the control and intervention period (6.5 ± 3.6 vs. 7.0 ± 3.5 mL/kg/hr, respectively, p=0.08). Length of hospital stay was significantly longer during the RBVM period compared to control (20.8 ± 29.7 days vs. 15.0 ± 22.2 days, respectively, p=0.04). There was no significant difference in length of stay in the ICU between the RBVM and control periods (15.3 ± 23.0 days vs. 10.0 ± 13.8 days, respectively, p=0.09). Of the patients with AKI (n=94), there was no difference in IDH events between the control and RBVM periods (IDH occurred in 25.9% vs. 24.3%, respectively, p=0.85).Table 1Baseline Demographics of Participants
All values are mean ± standard deviation; RBVM= relative blood volume monitoring ; ESKD=end stage kidney disease; AKI=acute kidney injury; HTN=hypertension; CVD=cardiovascular disease
Table 2Differences in Outcomes between Control and Relative Blood Volume Monitoring Periods
* Odds Ratio (95% CI) of outcome RBVM compared to control; RBVM=relative blood volume monitoring
Seventy-two patients received portable dialysis treatments in the ICU. Baseline demographics for ICU patients are shown in Table 1. When examining portable dialysis treatments delivered to patients in the ICU, there was a 29% reduced odds of IDH when using RBVM compared to the control period (OR 0.71, 95% CI 0.51-0.99, p=0.04, Table 2). Similar to the overall group, there were no significant differences in modifications to the dialysis treatments or patient symptoms during treatment with RBVM (Table 2). There was no difference in UF rate (6.2 ± 3.3 vs. 7.3 ± 4.2, respectively p=0.22) or length of stay (28.5 ± 29.4 days vs. 28.3 ± 40.0 days, respectively, p=0.21).Discussion:We found that the use of RBVM was associated with a 29% reduction in IDH in patients undergoing dialysis in the ICU. These finding suggest that RBVM may be useful to reduce IDH in critically ill patients. We did not find any significant difference in IDH with RBVM in all patients undergoing hemodialysis in the hospital. This may indicate that if patients are stable enough to be dialyzed in the acute dialysis unit and not at bedside then RBVM may not be as helpful at reducing IDH.
The majority of data regarding RBVM in dialysis comes from outpatient ESKD patients and is conflicting.5Balter P. Ficociello L.H. Taylor P.B. et al.A year-long quality improvement project on fluid management using blood volume monitoring during hemodialysis., 6Parker TF, 3rd, Hakim R, Nissenson AR, et al. A quality initiative. Reducing rates of hospitalizations by objectively monitoring volume removal. Nephrol News Issues. Mar 2013;27(3):30-2, 34-36.
, 7Reddan D.N. Szczech L.A. Hasselblad V. et al.Intradialytic blood volume monitoring in ambulatory hemodialysis patients: a randomized trial. Fewer studies have been performed in the inpatient setting. Critically ill patients are already prone to having hemodynamic instability and multi-organ dysfunction, and thus are at greater risk than general inpatients for developing hypotension and ischemic complications. Even a 5% reduction in IDH may be clinically meaningful. However, data regarding reductions in IDH and hard clinical outcomes in hospitalized patients are lacking.In a small study of 21 critically ill patients with sepsis and AKI, RBVM was found to be an easy and feasible tool to guide fluid management as investigators were able to maintain balance between UF and vascular refilling.9Kron S. Leimbach T. Wenkel R. Thieme U. Kern H. Kron J. Relative Blood Volume Monitoring during Renal Replacement Therapy in Critically Ill Patients with Septic Shock: A Preliminary Report. A small study of 20 adult patients with AKI found that the use of RBVM resulted in decreased IDH rates.S2 However, in a study of 74 critically ill patients with AKI, the use of RBVM did not reduce IDH in the ICU setting.S3 This study had a significantly lower rate of IDH (only 17%) compared to other studies. In our study, we did not find any significant reduction in IDH when examining only patients with AKI requiring RRT. In our ICU patients, a large percentage had ESKD. Hence, the use of RBVM to reduce IDH may differ in patients with AKI vs. ESKD and large prospective randomized studies are needed.Length of stay in the hospital was significantly longer in the intervention period. The reason for this is not clear but needs to be explored in future studies examining the use of RBVM in the hospital setting. Of note, length of stay in the ICU was not different between the two periods.
Our study does have limitations. First, this was not a randomized controlled trial. Additionally, we were not powered to detect differences in the outcomes as this was a quality improvement study. The number of patients undergoing dialysis in the ICU was small and may have limited power to detect significant differences. We defined AKI by chart review of nephrology notes, not by increases in serum creatinine levels. Finally, nursing competency in using RBVM was determined by supervisors and not by written knowledge testing. Strengths of this study include a large patient population for a quality improvement initiative, use of a run-in period to ensure nurses were capable and comfortable using RBVM and utilization of existing technology already on the dialysis machines with no significant change in or addition to the normal workflow of dialysis nurses and/or physicians.
In conclusion, the use of RBVM reduced IDH in critically ill patients undergoing intermittent hemodialysis in the ICU. These results suggest the need for a large, randomized controlled trial looking at use of RBVM in ICU patients undergoing dialysis and clinical outcomes.
AcknowledgementsFresenius Medical Care Renal Therapies Group provided support for this Investigator-Initiated Research Study. Statistical analysis support was provided by Linda H. Ficociello, DSc of Fresenius Medical Care, Global Medical Office.
Supplementary MaterialReferencesShingarev R. Wille K. Tolwani A.Management of complications in renal replacement therapy.
Semin Dial. Mar-Apr. 24: 164-168https://doi.org/10.1111/j.1525-139X.2011.00828.xSands J.J. Usvyat L.A. Sullivan T. et al.Intradialytic hypotension: frequency, sources of variation and correlation with clinical outcome.
Hemodial Int. Apr. 18: 415-422https://doi.org/10.1111/hdi.12138Obialo C.I. Hernandez B. Carter D.Delivered dialysis dose is suboptimal in hospitalized patients.
Am J Nephrol. 18: 525-530https://doi.org/10.1159/000013399Balter P. Artemyev M. Zabetakis P.Methods and challenges for the practical application of Crit-Line monitor utilization in patients on hemodialysis.
Blood Purif. 39: 21-24https://doi.org/10.1159/000368936Balter P. Ficociello L.H. Taylor P.B. et al.A year-long quality improvement project on fluid management using blood volume monitoring during hemodialysis.
Curr Med Res Opin. 31: 1323-1331https://doi.org/10.1185/03007995.2015.1047746Parker TF, 3rd, Hakim R, Nissenson AR, et al. A quality initiative. Reducing rates of hospitalizations by objectively monitoring volume removal. Nephrol News Issues. Mar 2013;27(3):30-2, 34-36.
Reddan D.N. Szczech L.A. Hasselblad V. et al.Intradialytic blood volume monitoring in ambulatory hemodialysis patients: a randomized trial.
J Am Soc Nephrol. Jul. 16: 2162-2169https://doi.org/10.1681/ASN.2004121053/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients.
Am J Kidney Dis. Apr. 45: S1-153Kron S. Leimbach T. Wenkel R. Thieme U. Kern H. Kron J.Relative Blood Volume Monitoring during Renal Replacement Therapy in Critically Ill Patients with Septic Shock: A Preliminary Report.
Blood Purif. 40: 133-138https://doi.org/10.1159/000433415Article InfoPublication HistoryAccepted: June 27, 2022
Received in revised form: June 9, 2022
Received: February 4, 2022
Publication stageIn Press Journal Pre-ProofFootnotesConflict of Interest Statement: Dr. Kendrick has received funding from Fresenius Medical Care Renal Therapies Group for investigator-initiated research. Statistical support was provided by Dr. Ficociello who is employed by Fresenius Medical Care.
Authors’ Contributions: MM, AB, JK contributed to the study conception and design. All authors contributed to data acquisition and interpretation. All authors contributed to the drafting, revising and final approval of the version to be published. All authors are in agreement to be accountable for all aspects of the work pre-and post-publication.
IdentificationDOI: https://doi.org/10.1016/j.ekir.2022.06.018
Copyright© 2022 Published by Elsevier Inc. on behalf of the International Society of Nephrology.
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