Interdialytic weight gain of less than 2.5% seems to limit cardiac damage during hemodialysis

Junko Goto, Ulf Forsberg, Per Jonsson, Kenichi Matsuda, Bo Nilsson, Kristina Nilsson Ekdahl, Michael Y Henein, Bernd G Stegmayr, Junko Goto, Ulf Forsberg, Per Jonsson, Kenichi Matsuda, Bo Nilsson, Kristina Nilsson Ekdahl, Michael Y Henein, Bernd G Stegmayr

Abstract

Aims: To investigate if a single low-flux HD induces a rise in cardiac biomarkers and if a change in clinical approach may limit such mechanism.

Material and methods: A total of 20 chronic HD patients each underwent three different study-dialyses. Dialyzers (low-flux polysulfone, 1.8 sqm) had been stored either dry or wet (Wet) and the blood level in the venous chamber kept low or high. Laboratory results were measured at baseline, 30 and 180 min, adjusted for the effect of fluid shift. Ultrasound measured microemboli signals (MES) within the return line.

Results: Hemodialysis raised cardiac biomarkers (p < 0.001): Pentraxin 3 (PTX) at 30 min (by 22%) and at 180 min PTX (53%), Pro-BNP (15%), and TnT (5%), similarly for all three HD modes. Baseline values of Pro-BNP correlated with TnT (rho = 0.38, p = 0.004) and PTX (rho = 0.52, p < 0.001). The changes from pre- to 180 min of HD (delta-) were related to baseline values (Pro-BNP: rho = 0.91, p < 0.001; TnT: rho = 0.41, p = 0.001; PTX: rho = 0.29, p = 0.027). Delta Pro-BNP (rho = 0.67, p < 0.001) and TnT (rho = 0.38, p = 0.004) correlated with inter-dialytic-weight-gain (IDWG). Biomarkers behaved similarly between the HD modes. The least negative impact was with an IDWG ⩽ 2.5%. Multiple regression analyses of the Wet-High mode does not exclude a relation between increased exposure of MES and factors such as release of Pro-BNP.

Conclusion: Hemodialysis, independent of type of dialyzer storage, was associated with raised cardiac biomarkers, more profoundly in patients with higher pre-dialysis values and IDWG. A limitation in IDWG to <2.5% and prolonged ultrafiltration time may limit cardiac strain during HD, especially in patients with cardiovascular risk.

Keywords: Biocompatibility; NT-pro-BNP; emboli; heart; hemodialysis; interdialytic weight gain; pentraxin; troponin.

Conflict of interest statement

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
(a) Pro-BNP at baseline in relation to the change of Pro-BNP at 180 min of dialysis (correlation analysis by Pearson test). (b) Troponin T at baseline in relation to the change of Troponin T at 180 min of dialysis (correlation analysis by Pearson test).
Figure 2.
Figure 2.
(a) Pro-BNP at baseline in relation to interdialytic weight gain (IDWG). The red line and r-value represents the whole material while the hatched line and r-value (above) represents IDWG ⩽ 2.5% and the full line represents IDWG values >2.5% (r-value above; correlation analysis by Pearson test). (b) Troponin T at baseline in relation to interdialytic weight gain (IDWG). The red line and r-value represents the whole material while the hatched line and r-value (above) represents IDWG ⩽ 2.5% and the full line represents IDWG values >2.5% (r-value above; n.s. = not significant; correlation analysis by Pearson test).
Figure 3.
Figure 3.
(a) Pro-BNP change from baseline to 180 min in relation to IDWG. The red line and r-value represents the whole material while the hatched line and r-value (above) represents IDWG ⩽ 2.5% and the full line represents IDWG values >2.5% (r-value above; correlation analysis by Pearson test). (b) Troponin T change from baseline at 180 min in relation to IDWG. The red line and r-value represents the whole material while the hatched line and r-value (above) represents IDWG ⩽ 2.5% and the full line represents IDWG values >2.5% (r-value above; n.s. = not significant; correlation analysis by Pearson test).

References

    1. Stirnadel-Farrant HA, Karaboyas A, Cizman B, et al.. Cardiovascular event rates among hemodialysis patients across geographical regions-A Snapshot from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Kidney Int Rep 2019; 4: 864–872.
    1. Madsen LH, Ladefoged S, Corell P, et al.. N-terminal pro brain natriuretic peptide predicts mortality in patients with end-stage renal disease in hemodialysis. Kidney Int 2007; 71: 548–554.
    1. Sommerer C, Beimler J, Schwenger V, et al.. Cardiac biomarkers and survival in haemodialysis patients. Eur J Clin Invest 2007; 37: 350–356.
    1. Kawagoe C, Sato Y, Toida T, et al.. N-terminal-pro-B-type-natriuretic peptide associated with 2-year mortality from both cardiovascular and non-cardiovascular origins in prevalent chronic hemodialysis patients. Ren Fail 2018; 40: 127–134.
    1. Alpert JS, Thygesen K, Antman E, et al.. Myocardial infarction redefined–a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol 2000; 36: 959–969.
    1. Speeckaert MM, Speeckaert R, Carrero JJ, et al.. Biology of human pentraxin 3 (PTX3) in acute and chronic kidney disease. J Clin Immunol 2013; 33: 881–890.
    1. Xu Y, Ding X, Zou J, et al.. Plasma pentraxin 3 is associated with cardiovascular disease in hemodialysis patients. Ren Fail 2011; 33: 998–1004.
    1. Liu H, Jiang Q, Ju Z, et al.. Pentraxin 3 promotes cardiac differentiation of mouse embryonic stem cells through JNK signaling pathway. Cell Biol Int 2018; 42: 1556–1563.
    1. Kume N, Mitsuoka H, Hayashida K, et al.. Pentraxin 3 as a biomarker for acute coronary syndrome: comparison with biomarkers for cardiac damage. J Cardiol 2011; 58: 38–45.
    1. Maugeri N, Rovere-Querini P, Slavich M, et al.. Early and transient release of leukocyte pentraxin 3 during acute myocardial infarction. J Immunol 2011; 187: 970–979.
    1. Apple FS, Murakami MM, Pearce LA, et al.. Predictive value of cardiac troponin I and T for subsequent death in end-stage renal disease. Circulation 2002; 106: 2941–2945.
    1. Sun L, Sun Y, Zhao X, et al.. Predictive role of BNP and NT-proBNP in hemodialysis patients. Nephron Clin Pract 2008; 110: c178–c184.
    1. Friden V, Starnberg K, Muslimovic A, et al.. Clearance of cardiac troponin T with and without kidney function. Clin Biochem 2017; 50: 468–474.
    1. Holmberg B, Stegmayr BG.Cardiovascular conditions in hemodialysis patients may be worsened by extensive interdialytic weight gain. Hemodial Int 2009; 13: 27–31.
    1. Zoccali C, Moissl U, Chazot C, et al.. Chronic fluid overload and mortality in ESRD. J Am Soc Nephrol 2017; 28: 2491–2497.
    1. Matsuda K, Fissell R, Ash S, et al.. Long-term survival for hemodialysis patients differ in japan versus europe and the usa. what might the reasons be? Artif Organs 2018; 42: 1112–1118.
    1. Wahl HG, Graf S, Renz H, et al.. Elimination of the cardiac natriuretic peptides B-type natriuretic peptide (BNP) and N-terminal proBNP by hemodialysis. Clin Chem 2004; 50: 1071–1074.
    1. Racek J, Kralova H, Trefil L, et al.. Brain natriuretic peptide and N-terminal proBNP in chronic haemodialysis patients. Nephron Clin Pract 2006; 103: c162–c172.
    1. Laveborn E, Lindmark K, Skagerlind M, et al.. NT-proBNP and troponin T levels differ after haemodialysis with a low versus high flux membrane. Int J Artif Organs 2015; 38: 69–75.
    1. Vienken J.Polymers in nephrology. Characteristics and needs. Int J Artif Organs 2002; 25: 470–479.
    1. Ekdahl KN, Soveri I, Hilborn J, et al.. Cardiovascular disease in haemodialysis: role of the intravascular innate immune system. Nat Rev Nephrol 2017; 13: 285-296.
    1. Abe M, Hamano T, Wada A, et al.. High-performance membrane dialyzers and mortality in hemodialysis patients: a 2-year cohort study from the annual survey of the Japanese Renal Data Registry. Am J Nephrol 2017; 46: 82–92.
    1. Jonsson P, Lindmark L, Axelsson J, et al.. Formation of blood foam in the air trap during hemodialysis due to insufficient automatic priming of dialyzers. Artif Organs 2018; 42: 533–539.
    1. Forsberg U, Jonsson P, Stegmayr C, et al.. A high blood level in the air trap reduces microemboli during hemodialysis. Artif Organs 2012; 36: 525–529.
    1. Stegmayr C, Jonsson P, Forsberg U, et al.. Hemodialysis dialyzers contribute to contamination of air microemboli that bypass the alarm system in the air trap. Int J Artif Organs 2008; 31: 317–322.
    1. Barak M, Nakhoul F, Katz Y.Pathophysiology and clinical implications of microbubbles during hemodialysis. Semin Dial 2008; 21: 232–238.
    1. Forsberg U, Jonsson P, Stegmayr B.Air contamination during medical treatment results in deposits of microemboli in the lungs: an autopsy study. Int J Artif Organs 2019; 42: 477–481.
    1. Stegmayr B, Brannstrom T, Forsberg U, et al.. Microbubbles of air may occur in the organs of hemodialysis patients. ASAIO J 2012; 58: 177–179.
    1. Forsberg U, Jonsson P, Stegmayr C, et al.. A high blood level in the venous chamber and a wet-stored dialyzer help to reduce exposure for microemboli during hemodialysis. Hemodial Int 2013; 17: 612–617.
    1. Forsberg U, Jonsson P, Stegmayr C, et al.. Microemboli, developed during haemodialysis, pass the lung barrier and may cause ischaemic lesions in organs such as the brain. Nephrol Dial Transplant 2010; 25: 2691–2695.
    1. Nilsson Ekdahl K, Nilsson B, Pekna M, et al.. Generation of iC3 at the interface between blood and gas. Scand J Immunol 1992; 35: 85–91.
    1. Madias JE.The impact of changing oedematous states on the QRS duration: implications for cardiac resynchronization therapy and implantable cardioverter/defibrillator implantation. Europace 2005; 7: 158–164.
    1. McAloon CJ, Barwari T, Hu J, et al.. Characterisation of circulating biomarkers before and after cardiac resynchronisation therapy and their role in predicting CRT response: the COVERT-HF study. Open Heart 2018; 5: e000899.
    1. Quan H, Sundararajan V, Halfon P, et al.. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005; 43: 1130–1139.
    1. Franz Faul EE, Lang A-G, Buchner A.G*Power 3-A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007; 39: 175–191.
    1. Fahim MA, Hayen A, Horvath AR, et al.. N-terminal pro-B-type natriuretic peptide variability in stable dialysis patients. Clin J Am Soc Nephrol 2015; 10: 620–629.
    1. Waldenstrom A, Ronquist G.Role of exosomes in myocardial remodeling. Circ Res 2014; 114: 315–324.
    1. Yigla M, Nakhoul F, Sabag A, et al.. Pulmonary hypertension in patients with end-stage renal disease. Chest 2003; 123: 1577–1582.
    1. Abassi Z, Nakhoul F, Khankin E, et al.. Pulmonary hypertension in chronic dialysis patients with arteriovenous fistula: pathogenesis and therapeutic prospective. Curr Opin Nephrol Hypertens 2006; 15: 353–360.
    1. Iglesias-Garriz I, Olalla-Gomez C, Garrote C, et al.. Contribution of right ventricular dysfunction to heart failure mortality: a meta-analysis. Rev Cardiovasc Med 2012; 13: e62–e69.
    1. Melenovsky V, Hwang SJ, Lin G, et al.. Right heart dysfunction in heart failure with preserved ejection fraction. Eur Heart J 2014; 35: 3452–3462.
    1. Jefferies HJ, Virk B, Schiller B, et al.. Frequent hemodialysis schedules are associated with reduced levels of dialysis-induced cardiac injury (myocardial stunning). Clin J Am Soc Nephrol 2011; 6: 1326–1332.
    1. McIntyre CW, Burton JO, Selby NM, et al.. Hemodialysis-induced cardiac dysfunction is associated with an acute reduction in global and segmental myocardial blood flow. Clin J Am Soc Nephrol 2008; 3: 19–26.
    1. Burton JO, Jefferies HJ, Selby NM, et al.. Hemodialysis-induced cardiac injury: determinants and associated outcomes. Clin J Am Soc Nephrol 2009; 4: 914–920.
    1. Selby NM, McIntyre CW.Peritoneal dialysis is not associated with myocardial stunning. Perit Dial Int 2011; 31: 27–33.
    1. Pryzdial ELG, Lee FMH, Lin BH, et al.. Blood coagulation dissected. Transfus Apher Sci 2018; 57: 449–457.
    1. Stenberg J, Lindberg M, Furuland H.Clinical praxis for assessment of dry weight in Sweden and Denmark: a mixed-methods study. Hemodial Int 2016; 20: 111–119.
    1. Stegmayr BG, Brannstrom M, Bucht S, et al.. Minimized weight gain between hemodialysis contributes to a reduced risk of death. Int J Artif Organs 2006; 29: 675–680.
    1. Westenbrink BD, Hovinga TK, Kloppenburg WD, et al.. B-type natriuretic peptide and interdialytic fluid retention are independent and incremental predictors of mortality in hemodialysis patients. Clin Nephrol 2011; 76: 373–379.
    1. Yilmaz R, Arici M, Yildirim T, et al.. Supplementary ultrafiltration may improve inflammation and cardiac dysfunction in patients with high interdialytic weight gain. Blood Purif 2012; 34: 67–74.
    1. Saran R, Bragg-Gresham JL, Levin NW, et al.. Longer treatment time and slower ultrafiltration in hemodialysis: associations with reduced mortality in the DOPPS. Kidney Int 2006; 69: 1222–1228.
    1. Charra B, Chazot C, Jean G, et al.. Long 3 x 8 hr dialysis: the Tassin experience. Nefrol Dializoterapia Polska 2006; 10: 141–146.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera