Dialysis initiation, modality choice, access, and prescription: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Globally, the number of patients undergoing maintenance dialysis is increasing, yet throughout the world there is significant variability in the practice of initiating dialysis. Factors such as availability of resources, reasons for starting dialysis, timing of dialysis initiation, patient education and preparedness, dialysis modality and access, as well as varied \u201ccountry-specific\u201d factors significantly affect patient experiences and outcomes. As the burden of end-stage kidney disease (ESKD) has increased globally, there has also been a growing recognition of the importance of patient involvement in determining the goals of care and decisions regarding treatment. In January 2018, KDIGO (Kidney Disease: Improving Global Outcomes) convened a Controversies Conference focused on dialysis initiation, including modality choice, access, and prescription. Here we present a summary of the conference discussions, including identified knowledge gaps, areas of controversy, and priorities for research. A major novel theme represented during the conference was the need to move away from a \u201cone-size-fits-all\u201d approach to dialysis and provide more individualized care that incorporates patient goals and preferences while still maintaining best practices for quality and safety. Identifying and including patient-centered goals that can be validated as quality indicators in the context of diverse health care systems to achieve equity of outcomes will require alignment of goals and incentives between patients, providers, regulators, and payers that will vary across health care jurisdictions

An investigation into the mechanisms, consequences and moderators of intradialytic hypotension in paediatric haemodialysis.

The relationship between hypertension and cardiovascular morbidity has long been recognised. However evidence is mounting implicating hypotension and not hypertension as the predominant risk factor for mortality. I demonstrated a 20-30% prevalence of intradialytic symptoms and hypotension in children during conventional, 4 hour haemodialysis (HD) sessions. The declining blood pressure (BP) was originally believed to be caused by ultrafiltration (UF) and priming of the HD circuit due to loss of fluid from the intravascular space. However data, largely in adults, challenged this hypothesis leading to a new consensus that intradialytic hypotension has a multifactorial aetiology. The uraemic milieu triggers a series of events that alters the cardiovascular compensatory responses to haemodynamic stresses, however the extent to which these physiological responses are impaired and their consequences are unknown and poorly understood. At first I corroborated adult findings that a poor correlation existed between relative blood volume changes and intradialytic hypotension in children, supporting the theory that fluid removal alone was not responsible for cardiovascular decompensation during HD and this assumption was a gross oversimplification of the underlying problem. Using a traditional method (endocardial wall motion) and a novel method (Speckle tracking 2-dimensional strain) I then measured the regional left ventricular (LV) function in children (aged 2 to 17 years) at the start of dialysis and again during peak stress at the end of HD. I found rising cardiac troponin I levels in 25% of the cohort and reduced regional LV function in all the children examined. The level of dysfunction significantly correlated with actual BP, the degree of intradialytic BP fall and UF volumes. What remains unclear however is whether the fall in BP was the cause or effect of the ischaemic cardiac injury. Finally I investigated dialysis methods for abrogating intradialytic morbidy in children treated with four hour HD sessions. A step sodium profile from 148mmol/l to 138mmol/l, prophylactic mannitol and sequential dialysis were successful, to variable degrees in attenuating intradialytic symptoms or hypotensive episodes. Intradialytic midodrine was exclusively used in one patient resistant to all other forms of therapy and was found to be the most efficacious in supporting the BP and preventing hypotension.

Are serum to dialysate sodium gradient and segmental bioimpedance volumes associated with the fall in blood pressure with hemodialysis?

Introduction: A fall in blood pressure is the most common complication of outpatient hemodialysis. Several factors have been implicated, including serum sodium to dialysate gradient, ultrafiltration rate, and the amount of fluid to be removed during dialysis.Methods: We prospectively audited 400 adult patients attending for their routine midweek hemodialysis session, and recorded changes in mean arterial blood pressure (MAP).Results: Mean age 58.4 ± 16.6 years, 60.9% male, 30.7% diabetic, 36.8% Caucasoid, single pool Kt/V 1.57 ± 0.4, and median percentage change in MAP -6.7% (-14.1 to + 2.8). The percentage fall in MAP was greatest for those starting with higher MAPs (β 0.448 ,F 67.5, p<0.001), greater serum sodium to dialysate sodium gradient (β 0.676, F 5.59, p = 0.019), and age (β 0.163, F 5.15, p = 0.024). In addition, the percentage fall in MAP was greater in those with the lowest segmental extracellular water/total body water (ECW/TBW) ratios in the right arm prior to dialysis (β -477.5, F 7.11, p = 0.008).Conclusions: Falls in blood pressure are common during dialysis, and greater for those starting dialysis with the highest systolic pressures, greater dialysate to serum sodium concentration gradient, and also those with the least ECW in the arm. As such, segmental bioimpedance may be useful in highlighting patients at greatest risk for a fall in blood pressure with dialysis.Journal Articleinfo:eu-repo/semantics/publishe