The hemodynamic effects during sustained low-efficiency dialysis versus continuous veno-venous hemofiltration for uremic patients with brain hemorrhage: a crossover study

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Object

Hemodynamic instability occurs frequently during dialysis treatment and remains a significant cause of patient morbidity and mortality, especially in patients with brain hemorrhage. This study aims to compare the effects of hemodynamic parameters and intracranial pressure (ICP) between sustained low-efficiency dialysis (SLED) and continuous veno-venous hemofiltration (CVVH) in dialysis patients with brain hemorrhage.

Methods

End-stage renal disease (ESRD) patients with brain hemorrhage undergoing ICP monitoring were enrolled. Patients were randomized to receive CVVH or SLED on the 1st day and were changed to the other modality on the 2nd day. The ultrafiltration rate was set at between 1.0 kg/8 hrs and 1.5 kg/8 hrs according to the patient's fluid status. The primary study end point was the change in hemodynamics and ICP during the dialytic periods. The secondary end point was the difference between cardiovascular peptides and oxidative and inflammatory assays.

Results

Ten patients (6 women; mean age 59.9 ± 3.6 years) were analyzed. The stroke volume variation was higher with SLED than CVVH (generalized estimating equations method, p = 0.031). The ICP level increased after both SLED and CVVH (time effect, p = 0.003) without significant difference between modalities. The dialysis dose quantification after 8-hour dialysis was higher in SLED than CVVH (equivalent urea clearance by convection, 62.7 ± 4.4 vs 50.2 ± 3.9 ml/min; p = 0.002). Additionally, the endothelin-1 level increased after CVVH treatment (p = 0.019) but not SLED therapy.

Conclusions

With this controlled crossover study, the authors provide the pilot evidence that both SLED and CVVH display identical acute hemodynamic effects and increased ICP after dialysis in brain hemorrhage patients. Clinical trial registration no.: NCT01781585 (ClinicalTrials.gov).

Abbreviations used in this paper:BNP = B-type natriuretic peptide; CVVH = continuous veno-venous hemofiltration; EKRjc = equivalent urea clearance by convection; ESRD = end-stage renal disease; ET-1 = endothelin-1; EVD = external ventricular drainage; GEE = generalized estimating equation; ICP = intracranial pressure; IL-6 = interleukin-6; NOx = nitrite + nitrate; RRT = renal replacement therapy; SLED = sustained low-efficiency dialysis; SV = stroke volume; SVI = stroke volume index; SVV = stroke volume variation; TBARS = thiobarbituric acid reactive substance.

Article Information

Address correspondence to: Kuo-Chuan Wang, M.D., Department of Neurosurgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei 100, Taiwan. email: wang081466@yahoo.com.tw.

Please include this information when citing this paper: published online May 24, 2013; DOI: 10.3171/2013.4.JNS122102.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Consort diagram illustrating the flow of participants. HD = hemodialysis; IE = inotropic equivalent.

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    Comparisons of the clinical parameters between the uremic patients with recent brain hemorrhage receiving CVVH and SLED by GEE method; all values are reported as the mean ± SEM. A: Mean blood pressure (MBP), between modality comparison, p = 0.591. B: The cardiac output (CO) between modality comparison, p = 0.750. C: The cardiac index (CI) between modality comparison, p = 0.550. D: The SV between modality comparison, p = 0.185. E: The SVI between modality comparison, p = 0.129. F: The SVV between modality comparison, p = 0.031 (GEE, standardized regression coefficient for SLED 18.5 [95% CI 1.7–35.4], p = 0.031). G: The ICP between modality comparison, p = 0.460. Changes in time period contributed to changes in ICP after 3 hours (GEE, standardized regression coefficient for time 2.7 [95% CI 1.1–4.3] in both modalities, p = 0.003 for first-order interaction).

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    Mean and individual values of ET-1 (A), IL-6 (B), TBARS (C), NOx (D), and pro-BNP (E) in CVVH and SLED at the start and the end of dialysis. *p < 0.05.

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