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Relationship of blood volume profiles to blood pressure changes and intradialytic morbidity (IM)
1995
SPRING
CLINICAL
NEPHROLOGY
MEETINGS
Al5
CRAMPING IN HEMODIALYSIS (I-ID), A SYMPTOM OF INTRADIALYTIC HYPOVOLEMIA. Robert R Steuer*. Michael J.Germain,David A.Bell*.*In-Line Diagnostics, Riverdale, Utah; BaystateMed. Ctr., Springfield, Mass. Cramping not only causesearly HD sessionsign-offs, but its etiology has remained obscure.We studied 56 chrome and/orhypovoleficsymptoms).me continuous_na~e of bloodvolume (HD) patients over 7 weekswhere changesin hematocrit monitoring (BVM) suggest it as an ideal prosoective indicator of and blood volume (ABV) were continuouslymonitored with conditions producing higher cardiovascular (CV) stress in hemodialysis GRIT-LINE (In-Line Diagnostics,Utah) to determine if (HD)patients:fluid overload (FO) or IM; whereas, change in blood cramping was causedby blood volume (BV) reduction pressure (BPA) is a retrospective indicator of both. We asked, “Can during HD. An intradialytic morbid event (IME) was 0 ProsDectively discriminate FO(A’s)andM (C’s)fromtheided defined as nurse intervention (NI) for “low blood pressure” with aggressive fluid removal and no IM (B’s)?” and/or symptoms (nausea/vomiting(N/V), lightheadedness We studied the BV profiles for every treatment of 56 chronic I-ILI (LH) or cramping). patients over 7 weeks. ABV was continuously monitored with CRITDuring the study, 262 IMEs occurred in 772 total HD LME (In-Line Diagnostics, Utah). Pre and post blood pressures (BP) sessionsfor an IM incidenceof 33.9%. RELATIONSHIP OF BLOOD VOLUME PROFILES TO BLOOD MORBIDITY (IM). PRESSURE CHANGES AND INTRADIALYTIC Robert R Steuer*, Michael J.Gcrmain, David A.Bell*. *In-Line Diagnostics, Riverdale, Utah; Baystate Med. Ctr., Springfield, Mass. Blood volume (BV) profiles may be defined as: “A’s” exhibiting <5% change in BV(ABV); or “B’s” exhibiting >5%ABV; or “C’s” exhibiting > ~%ABV d requiring intervention for IM (“low blood pressure”
were also recorded. Grouping patients by the BV profile most oflen incurred: Ave Ave Patient Type Pre-HD BP Post-HD BP BPA %ABV m, mm) cm -) (“w 132 f 10 124 f 10 -8 mm -4.2 f 1* A(19%) 145 fl7 132rL:7 -13 mm -18.3 f 3 B (37%) 143 f 23 123f7 -20 mm -19.5 f 5 c (44%) *p=O.O05 “A’s” different from either “B’s” or “C’s”. The data suggest: (1) Only 37% of the patients had ideal treatments (B’s),while the majority(63% of the patients)had treatments resulting in FO or IM; (2) A’s, with little BP or BV change, were easily and prospectively discriminated from B’s, suggesting the utility of BVM in reducing FO; but (3) %ABV did discriminate C’s from B’s (-18.3% vs. -19.5%). Therefore, BVM can prospectively identify FO conditions, but BVM alone cannot discriminate IM conditions.
TUBULAR &MtKERS IN DIABETES IN RELATION TO MICROANGIOPATHY O.Stoiceva-Tm N.Ivanov&i, RGrozdanov& T.Grue+, M.Polu&wic Dcpsrlment of Ncphrology, fnstitute for Clinical Biochemistry*,Facultyof Medic+, Skopje, Mac&o&a N-ace@B-D-glucos&n&s (NAG) is elevatedin urine and senun in diabeticsin the stagewhen microangiopathybeg&tocimlop,andisWnaideredaneariy ‘*Mer of diabetic nephropathy. B+2-microglobulin(Bs2M)isincreaaedinurineandeeruminanumberof cliseam with @hular clyhmction, including diabetes xnellitus.NAGand B-2M have beeti measuredin %vwn and urine in 21 diabetica,age 53.6~2.6 (9 malesand 12 females), 13/Z with NIDDM, and 8121with lDDM. TherewasaaignifxantincreaseinurinaryNAGinthe diabeticgroup when correlatedto the healthy cmmola (n=35),3.41+0.78 MI 0.739.36 4 well as urinary B-2M (0.43i 0.04 WI0.12+0,07) and serum B-2M (3.2tiO.32 vs 1.45~0,6)..9 out of 21 patients had &be& rctinopathy estimatedophtahnoacopically,urinary NAG leve& were signifkantly higher in the grovp with ret&pat& v8 those without it(6.323.8 M 1.2&l.@ p
(* p < 0.01, cramping and N/V comparedto Low BP) 94% of cramping (& 98% of N/V) occurred with a BV loss of at least 1O%,whereas84% of early sign offs due to Low BP only had greater than a 10% BV reduction. Further, 66% of cramping were not accompaniedby low BP, yet all had significantintradialytic hypovolemia. These data suggestthat the majority of intradialytic cramping events& NiV is due to hypovolemia. HIGHER RESPONSE RATE TO HEPATITIS B VACCINATION OBSERVED IN CHRONIC HEMODIALYSIS PATIENTS. Alexander M. Swan, Maria V. DeVita, Richard Chan, Paul M. Zabetakis, Michael F. Michelis, Nephrology Section, Department of Medicine, Lenox Hill Hospital, New York, New York. Previous data have revealed that only 50% of hemodialysis patients given hepatitis B vaccines produce antibody as compared to 95% of normal individuals. Predialysis patients may also have quite good responses to hepatitis B immunization. We reviewed our hemodialysis patient experience to assess how they responded to noninfectious recombinant DNA hepatitis B vaccine(Engerix-8). Each hemodialysis patient received four 40-microgram doses of vaccine at month 0, 1,2 and 6. Patients who refused to complete the whole course of vaccination were not included in the study. Our data showed that 85%(57 out of 67) of our hemodialysis patients reponded to the vaccination. Resoonder Nonresuonder p N(%) 57(85%) 10(15%) NS Age(years) 59+2 63+5 0.5 1.239.04 1.27+0.09 Kt/V 0.66 Albumin (gm/dl) 3.849.05 3.69kO.12 0.27 32.04kO.54 31.9k1.21 Hct(%) 0.92 185.3k6.03 188.8+10.94 Cholesterol(mg/dl) 0.78 27(47%) Polysulfone(%) 5(50%) NS Cellulose acetate(%) 30(53%) 5(50%) NS Our better response rate may be due to higher dosage and/or more frequent vaccination. There was no difference in regard to dialysis adequacy, degree of anemia, status of nutrition and type of dialyzer membrane. We conclude that majority of chronic hemodialysis patients respond well to hepatitis B vaccination. Hepatitis B vaccination should be encouraged in all dialysis patients.
SPRING
CLINICAL
NEPHROLOGY
MEETINGS
Al5
CRAMPING IN HEMODIALYSIS (I-ID), A SYMPTOM OF INTRADIALYTIC HYPOVOLEMIA. Robert R Steuer*. Michael J.Germain,David A.Bell*.*In-Line Diagnostics, Riverdale, Utah; BaystateMed. Ctr., Springfield, Mass. Cramping not only causesearly HD sessionsign-offs, but its etiology has remained obscure.We studied 56 chrome and/orhypovoleficsymptoms).me continuous_na~e of bloodvolume (HD) patients over 7 weekswhere changesin hematocrit monitoring (BVM) suggest it as an ideal prosoective indicator of and blood volume (ABV) were continuouslymonitored with conditions producing higher cardiovascular (CV) stress in hemodialysis GRIT-LINE (In-Line Diagnostics,Utah) to determine if (HD)patients:fluid overload (FO) or IM; whereas, change in blood cramping was causedby blood volume (BV) reduction pressure (BPA) is a retrospective indicator of both. We asked, “Can during HD. An intradialytic morbid event (IME) was 0 ProsDectively discriminate FO(A’s)andM (C’s)fromtheided defined as nurse intervention (NI) for “low blood pressure” with aggressive fluid removal and no IM (B’s)?” and/or symptoms (nausea/vomiting(N/V), lightheadedness We studied the BV profiles for every treatment of 56 chronic I-ILI (LH) or cramping). patients over 7 weeks. ABV was continuously monitored with CRITDuring the study, 262 IMEs occurred in 772 total HD LME (In-Line Diagnostics, Utah). Pre and post blood pressures (BP) sessionsfor an IM incidenceof 33.9%. RELATIONSHIP OF BLOOD VOLUME PROFILES TO BLOOD MORBIDITY (IM). PRESSURE CHANGES AND INTRADIALYTIC Robert R Steuer*, Michael J.Gcrmain, David A.Bell*. *In-Line Diagnostics, Riverdale, Utah; Baystate Med. Ctr., Springfield, Mass. Blood volume (BV) profiles may be defined as: “A’s” exhibiting <5% change in BV(ABV); or “B’s” exhibiting >5%ABV; or “C’s” exhibiting > ~%ABV d requiring intervention for IM (“low blood pressure”
were also recorded. Grouping patients by the BV profile most oflen incurred: Ave Ave Patient Type Pre-HD BP Post-HD BP BPA %ABV m, mm) cm -) (“w 132 f 10 124 f 10 -8 mm -4.2 f 1* A(19%) 145 fl7 132rL:7 -13 mm -18.3 f 3 B (37%) 143 f 23 123f7 -20 mm -19.5 f 5 c (44%) *p=O.O05 “A’s” different from either “B’s” or “C’s”. The data suggest: (1) Only 37% of the patients had ideal treatments (B’s),while the majority(63% of the patients)had treatments resulting in FO or IM; (2) A’s, with little BP or BV change, were easily and prospectively discriminated from B’s, suggesting the utility of BVM in reducing FO; but (3) %ABV did discriminate C’s from B’s (-18.3% vs. -19.5%). Therefore, BVM can prospectively identify FO conditions, but BVM alone cannot discriminate IM conditions.
TUBULAR &MtKERS IN DIABETES IN RELATION TO MICROANGIOPATHY O.Stoiceva-Tm N.Ivanov&i, RGrozdanov& T.Grue+, M.Polu&wic Dcpsrlment of Ncphrology, fnstitute for Clinical Biochemistry*,Facultyof Medic+, Skopje, Mac&o&a N-ace@B-D-glucos&n&s (NAG) is elevatedin urine and senun in diabeticsin the stagewhen microangiopathybeg&tocimlop,andisWnaideredaneariy ‘*Mer of diabetic nephropathy. B+2-microglobulin(Bs2M)isincreaaedinurineandeeruminanumberof cliseam with @hular clyhmction, including diabetes xnellitus.NAGand B-2M have beeti measuredin %vwn and urine in 21 diabetica,age 53.6~2.6 (9 malesand 12 females), 13/Z with NIDDM, and 8121with lDDM. TherewasaaignifxantincreaseinurinaryNAGinthe diabeticgroup when correlatedto the healthy cmmola (n=35),3.41+0.78 MI 0.739.36 4 well as urinary B-2M (0.43i 0.04 WI0.12+0,07) and serum B-2M (3.2tiO.32 vs 1.45~0,6)..9 out of 21 patients had &be& rctinopathy estimatedophtahnoacopically,urinary NAG leve& were signifkantly higher in the grovp with ret&pat& v8 those without it(6.323.8 M 1.2&l.@ p
(* p < 0.01, cramping and N/V comparedto Low BP) 94% of cramping (& 98% of N/V) occurred with a BV loss of at least 1O%,whereas84% of early sign offs due to Low BP only had greater than a 10% BV reduction. Further, 66% of cramping were not accompaniedby low BP, yet all had significantintradialytic hypovolemia. These data suggestthat the majority of intradialytic cramping events& NiV is due to hypovolemia. HIGHER RESPONSE RATE TO HEPATITIS B VACCINATION OBSERVED IN CHRONIC HEMODIALYSIS PATIENTS. Alexander M. Swan, Maria V. DeVita, Richard Chan, Paul M. Zabetakis, Michael F. Michelis, Nephrology Section, Department of Medicine, Lenox Hill Hospital, New York, New York. Previous data have revealed that only 50% of hemodialysis patients given hepatitis B vaccines produce antibody as compared to 95% of normal individuals. Predialysis patients may also have quite good responses to hepatitis B immunization. We reviewed our hemodialysis patient experience to assess how they responded to noninfectious recombinant DNA hepatitis B vaccine(Engerix-8). Each hemodialysis patient received four 40-microgram doses of vaccine at month 0, 1,2 and 6. Patients who refused to complete the whole course of vaccination were not included in the study. Our data showed that 85%(57 out of 67) of our hemodialysis patients reponded to the vaccination. Resoonder Nonresuonder p N(%) 57(85%) 10(15%) NS Age(years) 59+2 63+5 0.5 1.239.04 1.27+0.09 Kt/V 0.66 Albumin (gm/dl) 3.849.05 3.69kO.12 0.27 32.04kO.54 31.9k1.21 Hct(%) 0.92 185.3k6.03 188.8+10.94 Cholesterol(mg/dl) 0.78 27(47%) Polysulfone(%) 5(50%) NS Cellulose acetate(%) 30(53%) 5(50%) NS Our better response rate may be due to higher dosage and/or more frequent vaccination. There was no difference in regard to dialysis adequacy, degree of anemia, status of nutrition and type of dialyzer membrane. We conclude that majority of chronic hemodialysis patients respond well to hepatitis B vaccination. Hepatitis B vaccination should be encouraged in all dialysis patients.