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International Journal of Nephrology and Kidney Failure

Research Article Volume: 2.3 Open Access

Plasma Refilling in Hemodialysis: Determinant Received date: 28 Mar 2016; Accepted date: 26
May 2016; Published date: 31 May 2016.

Factors and Effects on Hemodynamic Citation: Alayoud A, Maoujoud O, Aattif T, El Kabbaj

D, Benyahia M, et al. (2016) Plasma Refilling in

Stability Hemodialysis: Determinant Factors and Effects

on Hemodynamic Stability. Int J Nephrol Kidney
Failure 2(3): doi http://dx.doi.org/10.16966/2380-
Alayoud A1*, Maoujoud O1, Aattif T2, El Kabbaj D2, Benyahia M2 and Zemraoui N3 5498.132
1
Service of Dialysis, Military Hospital Agadir, Morocco Copyright: © 2016 Alayoud A, et al. This is an
2
Service of Nephrology, Dialysis and Kidney Transplantation, Military Hospital of Instruction, Mohammed V open-access article distributed under the terms
Rabat, Morocco of the Creative Commons Attribution License,
3
Service of Nephrology, Dialysis and Kidney Transplantation, Military Hospital Avicenne, Marrakech, Morocco which permits unrestricted use, distribution, and
reproduction in any medium, provided the original
Corresponding author: Alayoud Ahmed, Service of Dialysis, Military Hospital Agadir, Morocco,
*
author and source are credited.
E-mail: [email protected]

Abstract
Background: The inadequate plasma refilling is the most important factor involved in the pathogenesis of dialysis discomfort. This work
explores the determinants factors of vascular refilling and its effects on hemodynamic stability in dialysis.
Methods: Cross-sectional study conducted in 35 hemodialysis patients. Relative blood volume (RBV) was performed by continuous optical
measurement of the haematocrit. Hydratation status was measured by bioelectrical impedance spectroscopy.
Results: Mean calculated refilling was 1423 ± 829 ml. The change of the interstitial volume was -1193 ± 859 ml (84% of refilling volume). The
change of the intracellular volume was -243 ± 124 ml. There is a significant correlation between the RBV at the end of dialysis and; Delta Prot
(post dialysis serum protein-Predialysis serum protein) (r=-0.7, p=0.01) , Delta Natremia (Sodium concentration at the end-Sodium concentration
at beginning) (r=0.46, p=0.032), interdialytic weight gain (r=-0.7, p<0.001) , Extracellular water before dialysis (r=-0.53, p=0.001), Total body
water before dialysis (r=-0.45, p=0.012), and Ultrafiltration rate (r=-0.85, p=0.0001). The change of systolic blood pressure (ΔSBP=Predialytic
SBP- Postdialytic SBP) increased while the RBV decreased at the end of dialysis (r= -0.5, p=0.007). Intradialytic hypotension was more frequent
with low RBV.
Conclusion: Several patient-related parameters and technique-related variables affect the plasma refilling, and their control can improve intra-
treatment hemodynamic stability during dialysis sessions.

Keywords: Plasma refilling; Dialysis; Hemodynamic stability; Hydratation status

Introduction Materials and Methods

Many factors have been implicated in the pathogenesis of hemodynamic Patients and haemodialysis treatments
instability during dialysis, including cardiac dysfunction, autonomic
35 chronic stables haemodialysis patients treated three times per
dysfunction and the imbalance between the ultrafiltration rate and the week from the Military Hospital of Instruction, Mohammed V (Rabat,
plasma refilling rate volume [1-3]. During haemodialysis (HD) the fluid Morocco)) were recruited to participate in this study after obtaining
is removed by ultrafiltration from the intravascular compartment, but informed consent. All patients studied were older than 18 years and
it naturally derived from the intravascular, interstitial and intracellular have intact arteriovenous fistulas. Haemodialysis was performed using
volume. This implies a continuous refilling of fluid from the extravascular Fresenius 5008 therapy system (Fresenius Medical Care,) and high flux
to the plasma compartments. The plasma refilling rate is the difference (Polyflux 170H, Polyflux 210H, and Polyflux 140H) (Gambro Healthcare)
between the total fluid loss and plasma volume loss per time unit. dialyzers. The duration of dialysis treatment was 4hours. The biofeed back
control (ultrafiltration control) was deactivated. No sodium modeling was
The inadequate plasma refilling is the most important factor involved in
used. Dialysate temperature was kept constant at 37°C. Average blood
the pathogenesis of dialysis discomfort [2]. Therefore, blood volume (BV), flow was 300 mL/m . Dialysate flow was set at 500 mL/m. Food and fluid
interstitial fluid volume and intracellular volume, play an important role intake was prohibited during the course of dialysis session.
in understanding fluid dynamics during HD and continuous registration
of plasma refilling with ultrafiltration (UF) is advocated as a tool to Measurements
maintain an adequate volume of the intravascular compartment to avoid Hydratation status (total body water, Extracellular and Intracellular
HD hypotension [1,4]. Changes in effective blood volume (EBV) can be volume) was measured before dialysis by bioelectrical impedance
measured by radio-isotope dilution techniques, but these methods are not spectroscopy using the Body Composition Monitor (BCM, Fresenius
easily applied on a routine basis. Changes in relative blood volume (RBV), Medical Care).
however, can be estimated by means of continuous haematocrit (HCT) During dialysis blood pressures (systolic diastolic and mean), pulse rate
measurements [3]. In this study we studied the determinants factors of was measured at 15 min intervals. Hypotension was defined as a systolic
vascular refilling and its effects on hemodynamic stability in dialysis. blood pressure <90 mmHg.

Copyright: © 2016 Alayoud A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Refilling and relative blood volume measurement There is a significant correlation between the RBV at the end of dialysis
(RBV final) and; DeltaProt(Post dialysis serum protein-Predialysis serum
Relative blood volume (RBV) was performed by continuous optical
protein) (r=-0.7, p=0.01) , Delta Natremia (Sodium concentration at the
measurement of the haematocrit using the Blood Volume Monitor (BVM)
end- Sodium concentration at beginning) (r=0.46, p=0.032), interdialytic
device (BVM, FMC). The mathematical formula used to determine RBV
weight gain (r=-0.7, p<0.001) , Extracellular water before dialysis (r=-
at moment t is:
0.53, p=0.001), total body water before dialysis (r=-0.45, p=0.012), and UF
rate (r=-0.85, p=0.0001) . There was not a significant correlation between
EBV current HCT starting the final RBV and intracellular water before dialysis (r=-0.19, p=0.278).
=RBVt =
EBV starting HCT current The change of the intravascular volume ΔVp was higher in diabetic
patients (p=0.04), and in the elderly (p=0,03), Neither there was no
So blood change during dialysis (ΔVb) is equal to plasma change (ΔVp): impact of gender(p=0.09).
ΔVp=ΔVb=Vb0( RBVt-1) There was a significant correlation between change of RBV and change
Blood volume (Vb0) at the beginning of the treatment was estimated of heart rate (r=-0.4, p=0.03) (Figure 1).
anthropometry from the Nadler Method based on the following formulas [5]: The change of systolic blood pressure (ΔSBP= Predialytic SBP-
For Males=0.3669 × Height in M3+0.03219 × Weight in kgs+0.6041 PostdialyticSBP) increased while the RBV decreased at the end of dialysis
(r= -0.5, p=0.007) (Figure 2).
For Females=0.3561 × Height in M3+0.03308 × Weight in kgs+0.1833
Intradialytic hypotension was more frequent with low RBV (the
During haemodialysis the fluid is removed by ultrafiltration (UF) from minimal RBV was 86 ± 2% in case of hypotension versus 95 ± 6% without
the intravascular (Vp), interstitial (Vis) and intracellular (Vic) volume. hypotension p=0.04).
ΔVT=-UF=ΔVp+ΔVic+ΔVis Discussion
The plasma refilling rate is the difference between the total fluid loss Like other studies we found that there was a significant correlation
and plasma volume loss between RBV with heart rate and ΔSBP, and intradialytic hypotension
Ref=ΔVp+ΔUF=-(ΔVic+ΔVis) (IDH) was more frequent with low RBV [7-10]. This suggests that a
reduction in RBV through ultrafiltration stimulates cardiovascular
Changes of Vic during dialysis can be modeled, from intracellular
defense mechanisms such as peripheral vasoconstriction and increasing
volume at the beginning (Vic starting) and the sodium concentration
(Na), according to this equation [6]:
Standard
Minimum Maximum Mean
 Na starting  Deviation
Vic =Vic starting ×  − 1 Minimal RBV (%) 75,9 98,0 91,4 4,9
 Na current  RBV at the end (%) 75,9 107,0 93,5 6,7
Data analysis Target weight (Kg) 41,0 90,0 63,9 11,6
Total UF volume (ml) 185 4000 1640,2 995,5
Comparative study was conducted using Student’s paired t-test.
Change of interstitial volume (ml) -3299,4 31,8 -1193,4 859,4
Correlation was assessed using Pearson’s coefficient and Spearman
Change of intracellular volume (ml) -1324,8 451,1 -243,7 124,3
coefficient for non parametric variable. A two sided p value 0.05 was
Change of plasma volume (ml) -1119,2 207,5 -261,3 191,4
considered significant. All statistical analyses were performed with the
Change of Extracellular volume (ml) -3757,4 226,6 -1426,2 1023,3
SPSS version 16 (SPSS Inc., Chicago, IL).
Refilling (ml) 379,7 3643,9 1423,2 829,5
Results Table 1: Ultrafiltration, Changes in fluid compartments and refilling data
16 women and 17 men with an average age of 50 ± 15 years were
enrolled in the study. They had been receiving haemodialysis for 60 ± 50 110
months. 15% were diabetics. The haematocrit at baseline was 33 ± 4%.
Serum protein before dialysis was 63 ± 4g/l.
Mean ultrafiltration volume was 1640 ± 995, with a mean body target 100
weight of 64 ± 11Kg; this represents 2.5% of the total body weight.
The RBV (%)

For all patients the RBV at the end was 93.5 ± 6.8%. Minimal value of
RBV was 91.4 ± 4.9%. For all measurements the average of RBV was 94.8 90
± 4.6 % with extremes ranging from 76 % to 108%.
Mean calculated refilling was 1423 ± 829 ml. The change of the
interstitial volume was -1193 ± 859 ml (84% of refilling volume). The
80
change of the intracellular volume was -243 ± 124ml; this represents 16 %
of the total refilling volume (Table1).
At the end of dialysis sessions, 87% of the fluid removed by ultrafiltration 70
had been refilled from the extra vascular space (13% from intra 40 50 60 70 80 90 100 110
vascular space).
The pulse rate ( beats / minute)
There is a significant correlation between ΔVic and the ratio of the
Figure 1: Correlation between the Relative Blood volume and the pulse
intracellular water to total body water before dialysis (p=0,03, r=0,48) ,
rate (r=-0.4, p=0.03)
and the conductivity (p=0,004, r=0,7).

Citation: Alayoud A, Maoujoud O, Aattif T, El Kabbaj D, Benyahia M, et al. (2016) Plasma Refilling in Hemodialysis: Determinant Factors and Effects on
Hemodynamic Stability. Int J Nephrol Kidney Failure 2(3): doi http://dx.doi.org/10.16966/2380-5498.132

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In our study the change of sodium concentration influences the
refilling rate. Indeed it is known that sodium is a potent osmotic regulator
of water distribution within the body, and transcellular fluid shifts in HD
patients [21]. Increasing of dialysate sodium concentration was proposed
to remove water from intracellular space with aim to optimize the refilling
and hemodynamic stability [6,22].

Conclusion
In this study the composition and the rate of vascular refilling
in dialysis was studied, and showed that several patient-related
parameters and technique-related variables affect the PRR, and their
control can improve intra-treatment hemodynamic stability during
dialysis sessions.

Acknowledgement
No conflict of interest.

Figure2: Correlation between the RBV at the end of dialysis and change References
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Citation: Alayoud A, Maoujoud O, Aattif T, El Kabbaj D, Benyahia M, et al. (2016) Plasma Refilling in Hemodialysis: Determinant Factors and Effects on
Hemodynamic Stability. Int J Nephrol Kidney Failure 2(3): doi http://dx.doi.org/10.16966/2380-5498.132

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Citation: Alayoud A, Maoujoud O, Aattif T, El Kabbaj D, Benyahia M, et al. (2016) Plasma Refilling in Hemodialysis: Determinant Factors and Effects on
Hemodynamic Stability. Int J Nephrol Kidney Failure 2(3): doi http://dx.doi.org/10.16966/2380-5498.132