Accurate intravascular volume assessment is critical in the treatment of patients who receive chronic hemodialysis (HD) therapy. Clinically assessed dry weight is a poor surrogate of intravascular volume; however, ultrasound assessment of the inferior vena cava (IVC) is an effective tool for volume management. This study sought to determine the feasibility of using operators with limited ultrasound experience to assess IVC dimensions using hand-carried ultrasounds (HCU) in the outpatient clinical setting. The IVC was assessed in 89 consecutive patients at two outpatient clinics before and after HD. Intradialytic IVC was recorded during episodes of hypotension, chest pain, or cramping. High-quality IVC images were obtained in 79 of 89 patients. Despite that 89% of patients presented at or above dry weight, 39% of these patients were hypovolemic by HCU. Of the 75% of patients who left HD at or below goal weight, 10% were still hypervolemic by HCU standards. Hypovolemic patients had more episodes of chest pain and cramping (33 versus 14%, P = 0.06) and more episodes of hypotension (22 versus 3%, P = 0.02). The clinic with a higher prevalence of predialysis hypovolemia had significantly more intradialytic adverse events (58 versus 27%; P = 0.01). HCU measurement of the IVC is a feasible option for rapid assessment of intravascular volume status in an outpatient dialysis setting by operators with limited formal training in echocardiography. There is a poor relationship between dry weight goals and IVC collapsibility. Practice variation in the maintenance of volume status is correlated with significant differences in intradialysis adverse events.

Handcarried Ultrasound Measurement of the Inferior Vena Cava for Assessment of Intravascular Volume Status in the Outpatient Hemodialysis Clinic

https://www.ajkd.org/article/S0272-6386(01)80124-4/pdf

Melatonin prevents oxidative stress resulting from iron and erythropoietin administration.

The effect of an increasing serum ionized calcium concentration on blood pressure during hemodialysis was studied in a prospective cross-over trial Twelve patients were dialyzed three times with a dialysate Ca concentration of 55 mg/dL and three times with one of 75 mg/dL Dialysis with the high Ca dialysate was associated with less fall in the mean arterial pressure (p less than 0001) No statistically significant changes occurred in serum osmolality, body weight, or heart rate after dialysis at the two dialysate Ca levels Increasing the Ca concentration in dialysate may protect against intradialytic hypotension in some patients

Blood Pressure Response to Changes in Serum Ionized Calcium During Hemodialysis

https://www.kidney-international.org/article/S0085-2538(15)58202-1/pdf

Non-invasive monitoring of blood volume during hemodialysis: Its relation with post-dialytic dry weight

The effectiveness of ramped hypertonic sodium dialysis (RHSD) is controversial because of the prevalence of side effects (weight gain and hypertension). Standard dialysis (SD) was therefore compared with RHSD in a double-blind controlled crossover trial. Eleven patients who suffered from symptoms attributable to water shifts from extracellular fluid to intracellular fluid (headaches or hangover) or extracellular-fluid volume contraction (cramps or lightheadedness) and five asymptomatic patients were enrolled in the study. RHSD was individually tailored to each patient (to minimize thirst) during a 2-wk run-in period. Patients then received RHSD and SD for a period of 3 wk in randomized sequence. Outcome measures were both objective and subjective ratings on questionnaires. Significant differences were found between the two treatments, with RHSD improving specific problems (70% of lightheadedness/cramps, 100% of headaches/hangover) versus SD. Weight gain and hypertension were not different between the two treatments despite increased thirst sensation reported by 14/16.94% of patients preferred RHSD. Long-term studies in 20 different patients demonstrated the lack of increase in blood pressure or weight gain after 3 and 6 months of therapy.

/pdf/the-benefits-and-side-effects-of-ramped-hypertonic-sodium-1h8afg116q.pdf

The benefits and side effects of ramped hypertonic sodium dialysis.

Hemodynamic study of hypotension during hemodialysis

Plasma perfused over immobilized protein A for breast cancer

. Plasma of twelve patients presenting with a metastic mammary adenocarcinoma was perfused ex vivo over columns of protein A covalently linked to crystalline silica. The plasma of seven patients (group A) was perfused over columns of protein A exhibiting a normal Fc-binding capacity and the plasma of five (group B) over columns of protein A in which the Fc-binding capacity was destroyed. In group A, all patients experienced acute, easily manageable, side effects (hypotension, chills, mild fever, leucocytosis and pain in tumour sites) during or immediately after the immunoadsorption procedures, and three exhibited an objective partial regression after two to five sessions. In contrast, none of the patients from group B developed any acute side effects and all showed evident progression of their disease during the treatment. Tumour cells in all stages of destruction, sometimes surrounded by extensive fibrosis, were seen in biopsies of patients A. However, focal areas of active tumour proliferation were always present in these patients. These data confirm that ex vivo perfusion over protein A columns of plasma from patients with cancer can induce a tumoricidal response in some instances and show that the Fc-binding capacity of protein A is most probably responsible for the necrolytic response and the side effects.

Ex vivo perfusion of plasma over protein A columns in human mammary adenocarcinoma. Role of the Fc-binding capacity of protein A in the side effects and the tumoricidal response.

Stimulation of platelet lipoxygenase during hemodialysis.

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Hemodynamic study of hypotension during hemodialysis

Plasma perfused over immobilized protein A for breast cancer

Ex vivo perfusion of plasma over protein A columns in human mammary adenocarcinoma. Role of the Fc-binding capacity of protein A in the side effects and the tumoricidal response.

Stimulation of platelet lipoxygenase during hemodialysis.