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Thermal Effects and Blood Pressure Response during Postdilution Hemodiafiltration and Hemodialysis: The Effect of Amount of Replacement Fluid and Dialysate Temperature

Department of Internal Medicine and Nephrology, University Hospital Maastricht, Maastricht, The Netherlands.

Correspondence to Dr. Frank M. van der Sande, Department of Internal Medicine and Nephrology, University Hospital Maastricht, P. Debeyelaan 25, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands. Phone: 31-433875007; Fax: 31-433875006; E-mail: FVS{at}sint.azm.nl

	Abstract

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Abstract. It has been suggested that the incidence of hypotensive episodes is less with hemodiafiltration (HDF) than with hemodialysis (HD). The aim of the present study was to assess the BP response during HD and postdilution HDF in relation to the thermal effects of these different treatment modalities by manipulating the dialysate temperature (Td) during HD and the amount of replacement fluid during HDF. In 12 patients, energy transfer rate (in watts) and maximal decline in mean arterial pressure during HD at Td 37.5°C, HD at Td 35.5°C, and postdilution HDF with amounts of replacement fluids infused at room temperature of 1 L/h and 2.5 L/h, respectively, were assessed. All measurements were done twice in each patient. Energy transfer rate was comparable between HD 35.5°C (-26.61 ± 5.33) and HDF 2.5 L/h (-25.25 ± 7.91) and was significantly more negative compared with HD 37.5°C (-3.53 ± 6.44) and HDF 1 L/h (-15.88 ± 6.94). The maximum decline in mean arterial pressure was significantly higher during HD 37.5°C (-25.6 ± 13.5) than during HD 35.5°C (-15.1 ± 13.8) and HDF 2.5 L/h (-19.2 ± 17.7), whereas there was no significant difference with HDF 1 L/h (-23.0 ± 14.0). In conclusion, thermal effects during postdilution HDF are dependent on the amount of replacement fluid. Also during HDF, the BP response is strongly related to thermal effects. The use of postdilution HDF with low or intermediate amounts of replacement fluids infused at room temperature seems to have no advantage in preventing hemodynamic instability, compared with HD 35.5°C.

	Introduction

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Hypotensive periods remain an important problem during hemodialysis (HD). Apart from great interindividual susceptibility, which seems to be at least partly related to the absence or presence of structural cardiovascular abnormalities, the most important initiating factors are a decline in blood volume and an impaired reactivity of the capacitance and resistance vessels. It is widely known that the incidence of symptomatic hypotension is lower with the use of purely convective techniques (hemofiltration and isolated ultrafiltration) because of a superior vascular reactivity during the latter (1). We and others (2,3,4) showed that this phenomenon between diffusive and convective techniques could be explained entirely by differences in thermal energy balance between these treatment modalities: during standard temperature dialysis, core temperature (CT) increases, which leads to vasodilation of cutaneous resistance and capacitance vessels, counteracting the normal vascular response to a decline in blood volume (4,5). Although the vascular response is greatly improved with the use of cool-temperature dialysate, all differences in arterial and venous response disappeared when convective and diffusive techniques were matched for the extracorporeal energy transfer (3,4).

It also has been suggested that the incidence of symptomatic hypotension is less with the use of hemodiafiltration (HDF) (6), although data are conflicting (7). The hemodynamic differences between HDF and HD have been attributed to differences in blood volume preservation (8) or to differences in the vasoconstrictor response (9).

Until now, there has been little knowledge regarding the energy transfer rate (ET) and BP response between HDF and HD at different dialysate temperatures.

In view of our previous results, the hypothesis is that hemodynamic differences between HD and HDF are dependent on thermal effects. The aim of the present study was to gain more insight in the hemodynamic differences between HD and HDF in relation to the thermal effects of these different treatment modalities. This was achieved by manipulating the dialysate temperature during HD and the amount of replacement fluid infused at room temperature during postdilution HDF.

	Materials and Methods

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Patients
Twelve stable patients (5 women and 7 men) were recruited from the chronic HD population from the University Hospital, Maastricht, The Netherlands. The patient group had a mean age of 56.67 ± 15.95 yr (range, 22 to 79 yr) and an average time on renal replacement therapy of 48.42 ± 41.64 mo (range, 8 to 144 yr). Renal disease was caused by chronic glomerulonephritis (two patients), hypertensive nephrosclerosis (four patients), focal segmental glomerulosclerosis (one patient), polycystic disease (one patient), amyloidosis (one patient), or focal segmental glomerulosclerosis (one patient) and was unknown in two patients. No patient had clinical cardiac disease or diabetes mellitus.

The following antihypertensive medication was used by the patients: angiotensin-converting enzyme inhibitors (four patients), ß-blocking agents (eight patients), calcium-channel blocking agents (eight patients), -blocking agents (one patient), angiotensin-II receptor antagonists (two patients), and direct vasodilatating agent (one patient).

All medication was continued to study daily clinical practice in the treatment of patients who were undergoing dialysis and were dependent on antihypertensive medication and was not changed during the study period. The patients also received their medication on the day of the study. All patients gave informed consent for the study.

Study Design
Patients were assessed during four dialysis sessions: standard-temperature HD (37.5°C; HD^37.5), cool-temperature HD (35.5°C; HD^35.5), postdilution HDF with a low amount of replacement fluid (exchange volume, 1 L/h; HDF¹), and HDF with an intermediate amount of replacement fluid (exchange volume, 2.5 L/h; HDF^2.5). During the HDF treatments, the dialysate temperature was 37.5°C. The replacement fluid was infused at room temperature (22°C) in postdilution mode. Replacement fluid was stored at ambient room temperature (22°C) and kept constant by controlling the temperature. The upper limit of 2.5 L/h was chosen because this is the maximum limit of the Fresenius 4008H device (Fresenius Medical Care, Bad Homburg, Germany), which is used in our clinic for HDF. The low amount of replacement fluid was chosen to observe whether the amount of substitution fluid infused has an impact on ET or BP.

Dialysis treatments were performed at the same time and day of the week to prevent large differences in ultrafiltration volume between the sessions, and each patient served as his or her own control thus eliminating as much bias as possible. Patients were ultrafiltrated until at dry weight, which was assessed by echography of the inferior caval vein performed 30 min after the end of dialysis (10). Treatment sessions with the different treatment modalities were performed in a randomized order. To obtain reproducible measurements, we conducted all measurements twice in each patient.

Dialysis Prescription
During each of the four treatment sessions, blood flow, dialysate flow, dialysate composition, and treatment time were the same. The composition of the dialysate used during HD and HDF was bicarbonate individualized 32 to 36 mmol/L, 140 mmol/L sodium, 1.75 mmol/L calcium, 3 mmol/L acetate, 2 mmol/L potassium, 0.5 mmol/L magnesium, and 108 mmol/L chloride. Polyamide membranes (Polyflux 14S; Gambro, Lund, Sweden) were used during both HD and HDF. Ultrapure dialysate that contained <0.1 CFU/ml and <0.03 IU/L endotoxin (LAL-test) was used.

The composition of the replacement fluid was 140 mmol/L sodium, 1.875 mmol/L calcium, 45.5 mmol/L lactate, 1 mmol/L potassium, 0.75 mmol/L magnesium, and 101 mmol/L chloride (HF1; Baxter, Uden, The Netherlands). Blood flow, which can have a significant influence on ET (11), was 300 ml/min in all sessions.

Energy Transfer Rate
During each treatment session, temperature at the arterial (T_art) and venous (T_ven) side of the fistula, as well as ET between the extracorporeal circuit and the patient, were monitored at 10-s intervals.

ET was defined as the amount of thermal energy that was transferred from the extracorporeal circuit to the patient or vice versa. A positive value indicates net energy gain from the extracorporeal circuit to the patient, and a negative value indicates net heat loss from the patient to the extracorporeal circuit. ET (in watts) was calculated by use of the following formula: c x x Qb x (T_art — T_ven), where c is the specific thermal capacity (3.64 kJ/kg x °C), Qb is extracorporeal blood flow, and is density of blood (1052 kg/m³) (12).

T_art and T_ven were assessed with the use of continuous temperature monitoring at the arterial and venous side of the extracorporeal system by an air-filled head with a platinum sensor (Blood Temperature Monitoring [BTM]; Fresenius Medical Care) around the arterial and venous blood lines (3,5,11). The coefficient of variance of ET measurements for HDF¹ and HDF^2.5 were 7.1% and 6.8%, respectively.

Resting energy expenditure (REE) was predicted according to the Harris-Benedict equation (13). Men: REE = 66 + 13.8 x weight + 5 x height - 6.8 x age (kcal/24 h); women: REE = 655 + 9.7 x weight + 1.8 x height - 4.7 x age (kcal/24 h). To obtain values in watts (1 W = 0.86 kcal/h), values were divided by 20.64.

Core Temperature
CT was measured by use of the BTM described above. The BTM measures the temperature at the arterial side of the fistula and calculates central venous blood temperature by correcting for fistula and cardiopulmonary recirculation. This temperature is referred to as CT. The correction is necessary because the arterial blood temperature is determined by the CT as well as by the temperature of the recirculated venous blood. Recirculation is measured by the BTM with a temperature bolus that is produced by a temporary change in dialysate temperature. The change in temperature is recorded by the venous sensor head of the BTM and finally by the arterial sensor head. From the ratio in bolus sizes, recirculation can be calculated (11). Predialytic CT was defined as the first reliable temperature obtained (in all patients within 5 min) after the start of dialysis. The accuracy of the BTM CT is better than ±0.05°C, and the reproducibility is better than ±0.01°C as given by the manufacturer.

BP
BP and heart rate were assessed every 15 min with the use of an automated oscillometric BP monitor (Dinamap 1486 SX; Critikon Inc., Tampa, FL). The maximal decline in mean arterial pressure (MAP) during dialysis was included for analysis.

Blood Volume
Changes in relative blood volume during the different treatment modalities were determined by on-line measurements of total protein concentration (Blood Volume Monitor; Fresenius Medical Care, Lexington, MA) according to the formula BV_t/BV_o = (TPC_o — TPC_t/TPC_t — TPC_ex) x 100%. Subscripts 0 and t apply to conditions at time t and 0, whereas TPC_ex refers to the amount of protein exchanged between the blood and extravascular compartment, which is assumed to be 7 g/L (11).

Statistical Analyses
The comparison between the values between the different treatments were analyzed by Friedman's ANOVA and, when appropriate, by the Wilcoxon's signed rank test (SPSS version 10.0: SPSS, Inc., Chicago, IL). P < 0.05 was considered to be significant. Data are expressed as mean ± SD.

	Results

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Body Weight and Ultrafiltration Volume
The predialysis weight in the four treatment sessions HD^37.5, HD^35.5, HDF¹, and HDF^2.5 were 68.4 ± 13.4, 68.2 ± 13.3, 68.2 ± 13.4, and 68.2 ± 13.2 kg, respectively (not significant). Ultrafiltration volume in the treatment sessions was 2.2 ± 0.61, 2.3 ± 0.71, 2.4 ± 0.71, and 2.3 ± 0.8 L, respectively (not significant). In all patients during all sessions, the prescribed dry weight was achieved.

Energy Transfer Rate
ET (Table 1) gave a significant negative value during HD^35.5, HDF¹, and HDF^2.5, whereas there was not significant ET during HD^37.5.

The difference in ET between HD^37.5 and all other treatment modalities was highly significant (P < 0.001), as was the difference between HD^35.5 and HDF¹ (P < 0.05) and between HDF¹ and HDF^2.5 (P < 0.05). The difference in ET between HD^35.5 and HDF^2.5 was not significant.

The estimated REE was 69.11 ± 10.95 W. The ET during HD^37.5, HD^35.5, HDF¹, and HDF^2.5 approximates 5 ± 10%, 39 ± 10%, 23 ± 11%, and 37 ± 14%, respectively, of the estimated REE.

Core Temperature
The predialysis CT before HD^37.5, HD^35.5, HDF¹, and HDF^2.5 was 36.7 ± 0.26°C, 36.5 ± 0.35°C, 36.6 ± 0.25°C, and 36.6 ± 0.30°C, respectively (not significant). CT increased significantly during HD^37.5 and HDF¹ and did not change significantly during HD^35.5 and HDF^2.5 (Table 1). The change in CT was significantly different between all different treatment modalities (P < 0.025), except for the difference between HD^35.5 and HDF^2.5.

BP
The maximum decline in MAP (Table 1) was most pronounced during HD^37.5 and differed significantly from HD^35.5 and HDF^2.5 (P < 0.05), whereas the differences between HD^37.5 and HDF¹ did not reach significance. The decline in MAP was significantly more pronounced during HDF¹, compared with HD^37.5, whereas no significant differences were observed between both HDF treatments.

Blood Volume
The decrease in blood volume versus baseline in the four treatment sessions is summarized in Table 1. Blood volume decreased significantly versus baseline during all four treatment sessions; however, there were no significant differences between the four treatment sessions.

	Discussion

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The data of our study show that the amount of replacement fluid infused at room temperature during postdilution HDF has a significant effect on ET and changes in CT during the treatment. Moreover, these thermal changes had a significant effect on the BP response during HDF.

The loss of extracorporeal energy during postdilution HDF is in agreement with earlier data (9). However, the difference between the present study and data of Maggiore et al. (9) is that those authors used fixed and relatively high exchange volumes (120 ml/min) in combination with a high dialysate temperature (39.3°C) and compared only thermal effects of HDF with standard temperature (37.5°C) HD. Moreover, BP stability was not compared in the study of Maggiore et al. Of course, because no standard prescription for HDF exists, amounts of replacement fluid in our study were chosen arbitrarily with respect to the limitations of the dialysate module. Therefore, the mode of HDF (predilution versus postdilution), changes in amount of replacement fluid, blood flow, and dialysate or infusate temperatures may yield results that are different from the present study. Theoretically, ET during predilution HDF will depend mainly on the temperature of the dialysate, whereas with postdilution HDF ET will be more dependent on the temperature of the replacement fluid. With on-line HDF, the infusate temperature will, by definition, be equal to the dialysate temperature. It is interesting that, in the present study, ET gave only a 60% more negative value during HDF^2.5, compared with HDF¹, whereas amount of replacement fluid increased by >150% during HDF^2.5. An explanation for the lack of the linear relation between ET and the amount of replacement fluid is that, also during postdilution HDF, ET depends on the thermal effects of both the dialysate and the replacement fluid. Moreover, ET is a function of temperature in the arterial and venous blood lines. That the temperature in the arterial blood line increases during HDF¹ and remains stable during HDF^2.5 also might contribute to the absence of linear relation. Because of the complexity of these relations, the results of the present study at least suggest that thermal effects of different dialysis modalities should be measured directly.

CT increased during HD^37.5, although there was no significant ET, and during HDF¹, despite a net energy loss from the patient to the extracorporeal circuit. The increase in CT during dialysis treatment in patients without a significant ET or in patients with a net energy loss to the extracorporeal circuit is in agreement with previous reports (3,4,5,9,14). The pathophysiology of this phenomenon still is not completely elucidated. It was hypothesized by Gotch et al. (15) that initial vasoconstriction in response to volume removal could lead to reduced heat loss of the skin, which is supported by the findings of Rosales et al. (16), who found a significant relation between (indexed) ultrafiltration volume and thermal balance. However, with direct hemodynamic measurements of the forearm vasculature, we already observed a reduced vascular reactivity of forearm capacitance and resistance vessels early after the beginning of the dialysis treatment (17,18). Another hypothesis is that cytokine production could play a role in the increase in CT during dialysis. However, although cytokine production was not measured in the present study, ultrapure dialysate, sterile replacement fluids, and biocompatible membranes were used. Mean CT remained stable during HD^35.5 and HDF^2.5, which are characterized by a more negative ET compared with the other treatments. This suggests that the loss of energy over the extracorporeal circuit during cool dialysis prevents an increase in CT.

Regarding the hemodynamic response, the largest decline in BP was observed during the treatment modalities that were characterized by an increase in CT (HDF¹ and UF-HD^37.5). This strongly suggests that, also during HDF, thermal effects are primary determinants of the BP response. Because this is in accordance with our previous findings with regard to hemofiltration and isolated ultrafiltration (2,3), it is likely that the improved BP response during HD^35.5 and HDF^2.5 is due to a more physiologic vascular reactivity, because the increase in CT, leading to cutaneous vasodilation, is prevented by the energy loss from the patient to the extracorporeal circuit. Also of interest is that the BP response clearly was not superior during HDF treatments, compared with cool-temperature dialysis, which suggests that it is not the convective treatment per se but the thermal effects of the dialysis modality that determine the BP response during the treatment.

Changes in blood volume were comparable between the various treatment modalities. Again, we could not reproduce the finding of Schneditz et al. (11), who found a larger decline in blood volume during cool-temperature HD compared with standard HD. Schneditz et al. explained this phenomenon by a reduction in capillary surface area caused by increased vasoconstriction. However, in contrast, it could be hypothesized that a decrease in precapillary hydrostatic pressure caused by the increased vasoconstriction (3) would actually improve refill of blood volume during cool-temperature HD.

In conclusion, thermal effects during postdilution HDF with replacement fluids infused at room temperature are dependent on the amount of the replacement fluid. The thermal effects of cool-temperature dialysis and HDF^2.5 with replacement fluid infused at room temperature are comparable. Also during HDF, the BP response is strongly related to thermal effects. For the maintenance of hemodynamic stability, postdilution HDF with relative standard replacement volumes infused at room temperatures holds no advantage over cool dialysis.

	References

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