Determinants of Hemodynamic Stability and Patient Reported Outcomes in Hemodialysis

Abstract

Patients on maintenance hemodialysis (HD) suffer from disproportionately high morbidity and mortality, with up to a 15-fold higher risk death compared to age-matched individuals without end-stage kidney disease.(1–3) This high disease burden is in part related to hemodialysis treatments themselves which induce systemic fluctuations in volume and serum osmoles that can destabilize blood pressure, trigger intracellular fluid shifts, and precipitate end-organ injury.(4–7) Intradialytic hypotension (IDH) is one of the most frequent complications of HD, with a prevalence of 8-40% and is a major risk factor for cardiovascular disease and mortality.(7–9) IDH can provoke ischemic symptoms such as chest pain and muscle cramps, however there are over a dozen intradialytic symptoms common to HD that can occur independent of blood pressure.(10,11) Intradialytic symptoms occur in up to 75% of patients and are associated with reduced quality of life and risk for depression, which can occur in up to 25% of the HD population(2,3,12,13) Both IDH and intradialytic symptoms can be severe enough to impair the delivery HD, which in turn can predispose patients to additional risk associated with inadequate renal replacement. (7,14,15) Although the precise pathogeneses of both IDH and intradialytic symptoms is incompletely understood, they are associated with the intensity of hemodialysis itself. This is illustrated by the clinical management of these disease entities, which often involves reducing either the efficiency or duration of the dialysis session.(7,10,16) This underscores the crucial need to identify risk factors for IDH or intradialytic symptoms that a) are high-yield, inexpensive and modifiable and b) will not negatively impact the adequacy of HD treatments.(17) With this in mind, I have chosen to explore the role of intradialytically-administered iron sucrose and calculated pre-HD serum osmolarity in the manifestation of intradialytic complications.