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NDT Advance Access originally published online on October 19, 2007
Nephrology Dialysis Transplantation 2008 23(3):1066-1067; doi:10.1093/ndt/gfm741
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© The Author [2007]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org


Glucose-added dialysis fluid prevents asymptomatic hypoglycaemia in regular haemodialysis

E-mail: daniel.schneditz{at}meduni-graz.at

Sir,

It is with much interest that I read the article on haemodialysis-associated hypoglycaemia by Jayme E. Burmeister et al., published in the April issue of NDT [1]. The authors reported that arterial glucose concentrations dropped to 21 mg/dL (1.2 mmoL/L) in one diabetic patient and to 60 mg/dL (3.3 mmoL/L) in another non-diabetic patient, without clinical symptoms when using glucose-free dialysate. Arterial blood samples, however, were drawn from the extracorporeal blood line.

Given the absence of symptoms in spite of severe extracorporeal hypoglycaemia, I would like to direct attention to recirculation, which may have led to such low concentrations [2,3]. The effects of recirculation have been studied for urea kinetics in much detail; however, these considerations extend to other solutes with high extracorporeal gradients such as glucose, especially when using a glucose-free dialysate. The considerations also extend to arterial and venous blood temperatures, which can therefore be used to measure recirculation [4].

The following equation can be used for computing systemic arterial (cs) from arterial line concentrations (ca) and overall recirculation (R, given as a fraction):

Formula (1)
where Qb and Kd refer to extracorporeal blood flow and dialyzer clearance, respectively. For example, when blood lines are inadvertently switched, which occurs more frequently than anticipated, recirculation may reach values in the range of R = 0.5. Assuming realistic values for Qb = 0.3 and Kd = 0.15 L/min, respectively, it follows from equation (1) that fR = 0.67. Thus, the arterial line concentration (ca = 21 mg/dL) is erroneously low and represents only 67% of the systemic concentration (cs = 31 mg/dL). However, blood lines do not have to be switched for recirculation to occur. In a malfunctioning access, R may be higher than 0.5, even with correct placement of blood lines, and the value of fR may become even smaller. The true systemic concentration will therefore be underestimated if not accounting for recirculation.

The opposite effect may occur when a normo-glycaemic patient is dialyzed with a high glucose dialysate, e.g. at a concentration of 200 mg/dL. In this case, recirculation will lead to false high arterial line concentrations, and the true systemic concentration will be overestimated if not accounting for recirculation.

Therefore, when studying systemic effects of solutes readily exchanged with the dialysate, it is also necessary to measure recirculation. Since effects are caused both by access and cardiopulmonary recirculation [5], systems capable of measuring both components of recirculation will be helpful to determine the correct systemic concentration. We have successfully used such a system in our studies, using temperature as an indicator and automatically measuring recirculation by changing the dialysate temperature for a short period of time [6]. Because the indicator dissipates, measurements do not interfere with the treatment and can be repeated as often as desired [7].

Transparency declaration

The author has worked with the blood temperature monitor (BTM) to measure recirculation and has received financial as well as material support from the manufacturer of the BTM, Fresenius Medical Care, Germany.

Conflict of interest statement. None declared.

Daniel Schneditz

Institute of Physiology Medical University of Graz

References

  1. Burmeister JE, Scapini A, da Rosa Miltersteiner D, et al. Glucose-added dialysis fluid prevents asymptomatic hypoglycaemia in regular haemodialysis. Nephrol Dial Transplant (2007) 22:1184–1189.[Abstract/Free Full Text]
  2. Gotch FA. Models to predict recirculation and its effect on treatment time in single-needle dialysis. In: First International Symposium on Single-Needle Dialysis—Ringoir S, Vanholder R, Ivanovich P, eds. (1984) Cleveland: ISAO Press. 305.
  3. Depner TA. Prescribing Hemodialysis: A Guide to Urea Modeling (1991) Boston/Dordrecht/London: Kluwer.
  4. Schneditz D, Wang E, Levin NW. Validation of hemodialysis recirculation and access blood flow measured by thermodilution. Nephrol Dial Transplant (1999) 14:376–383.[Abstract/Free Full Text]
  5. Schneditz D, Kaufman AM, Polaschegg HD, et al. Cardiopulmonary recirculation during hemodialysis. Kidney Int (1992) 42:1450–1456.[Web of Science][Medline]
  6. Wang E, Schneditz D, Kaufman AM, et al. Sensitivity and specificity of the thermodilution technique in detection of access recirculation. Nephron (2000) 84:134–141.
  7. Wang E, Schneditz D, Ronco C, et al. Surveillance of fistula function by frequent recirculation measurements during high-efficiency dialysis. ASAIO J (2002) 48:394–397.[CrossRef][Web of Science][Medline]

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This Article
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