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Abstract: PO0853

Variability of Plasma Refill Rate and Risk of Intradialytic Hypotension During Maintenance Hemodialysis

Session Information

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis

Authors

  • Wang, Hao, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
  • Negoianu, Dan, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
  • Zhang, Hanjie, Renal Research Institute, New York, New York, United States
  • Rogg, Sabrina, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Hessen, Germany
  • Hsu, Jesse Yenchih, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
  • Kotanko, Peter, Renal Research Institute, New York, New York, United States
  • Raimann, Jochen G., Renal Research Institute, New York, New York, United States
  • Dember, Laura M., University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
Background

Continuous hematocrit data can be combined with time-updated ultrafiltration data to non-invasively estimate a semi-instantaneous plasma refill rate (PRR) throughout hemodialysis. The PRR is a dynamic metric that varies throughout hemodialysis, even during periods of constant rates of ultrafiltration, and is influenced by oncotic and hydrostatic forces. We aimed to determine whether variability in PRR is associated with intradialytic hypotension (IDH).

Methods

We used data from continuous hematocrit monitoring performed at 17 dialysis units from January 2017-October 2019 to calculate intradialytic plasma refill rates standardized to weight and height. PRR variability was defined as the coefficient of variance in PRR (PRRcov) every 15 minutes and categorized into three groups: low (PRRcov < 1.0), moderate (PRRcov 1.0-2.0) and high (PRRcov > 2.0). IDH was defined in three ways: (1) nadir systolic blood pressure (SBP) < 90 mmHg, (2) SBP < 90 mmHg or associated symptoms, and (3) either drop in SBP of 20 mmHg or mean arterial blood pressure of 10 mmHg with associated symptoms. Cox proportional hazard regression was used to assess the impact of starting PRR variability on time to first IDH. Marginal structural modeling was used to assess the impact of time-updated plasma refill rate variability on the risk of IDH.

Results

Among 2350 patients and 184,453 hemodialysis sessions, mean session time was 220 ± 26 min and ultrafiltration rate was 9.0 ± 3.3 ml/kg/hr. Median PRRcov was 1.20 (IQR 0.68, 2.18) across all sessions. Compared to hemodialysis sessions with low PRRcov, sessions with high PRRcov in the first 15 minutes of treatment were associated with a 1.14 hazard of intradialytic hypotension (95% CI 1.05, 1.24). Accounting for repeated measures and changes in systolic blood pressure and ultrafiltration, sessions with high PRRcov throughout the duration of hemodialysis were associated with an increased risk of IDH based across definitions: definition 1 (OR 1.29, 95% CI 1.16, 1.43), definition 2 (OR 1.85, 95% CI 1.77, 1.94), and definition 3 (OR 1.87, 95% CI 1.78, 1.98).

Conclusion

PRR variability was associated with higher risk of IDH, independent of time-varying confounding from SBP and UFR. PRR variability could be a promising bedside metric for hemodynamic instability during hemodialysis.

Funding

  • NIDDK Support