Full text of DOI:10.1016/S0272-6386(00)70250-2

Cardiac and Hemodynamic Effects of Hemodialysis
and Ultrafiltration
Willem Jan W. Bos, MD, Sjoerd Bruin, MSc, Rudolf W. van Olden, MD, Ingrid Keur, MD,
Karel H. Wesseling, MSc, Nico Westerhof, MD, Raymond T. Krediet, MD,
and Lambertus A. Arisz, MD
● Imbalance between cardiac oxygen supply and demand may trigger cardiac events in already vulnerable
hemodialysis (HD) patients. We studied the effect of ultrafiltration (UF) and HD in nine chronic HD patients by
continuously measuring blood volume (BV; by Critline), blood pressure (BP; by Portapres), and changes in
hemodynamics (Modelflow) during isolated UF (iUF) of 500 mL in 30 minutes and subsequent HD combined with UF
(HD ؉ UF). Aortic pressure was reconstructed from finger pressure. Changes in cardiac oxygen supply were
assessed by calculating the area under the aortic pressure curve during diastole (diastolic pressure time index
[DPTI]). Changes in cardiac oxygen demand were assessed by calculating systolic pressure time index (SPTI). BV
decreased 4.0% ؎ 1.8% during UF and 7.3% ؎ 3.3% during HD ؉ UF (both P F 0.01). Systolic BP did not change;
diastolic and mean BP increased 11 ؎ 7.4 and 11 ؎ 8.4 mm Hg during iUF, respectively (both P F 0.01), and
stabilized during HD ؉ UF. Overall pulse pressure decreased 19 ؎ 11.1 mm Hg (P F 0.01). Heart rate increased 13 ؎
11 beats/min (P F 0.01) and systemic vascular resistance increased 59% ؎ 51% (P F 0.01), whereas stroke volume
and cardiac output (CO) decreased by 40% ؎ 17% and 30% ؎ 13%, respectively (both P F 0.01). Both cardiac
oxygen supply (DPTI) and demand (SPTI) increased during iUF, and both decreased during HD ؉ UF. By the end of
the procedure, DPTI/SPTI ratio had increased 9% ؎ 8% (P F 0.05). Changes in CO correlated closely to changes in
BV. Despite large changes in hemodynamics during uncomplicated UF and HD, the balance between cardiac
oxygen supply and demand (DPTI/SPTI ratio) did not decrease, but improved slightly.
2000 by the National Kidney Foundation, Inc.
௠
INDEX WORDS: Hemodialysis (HD); hemodynamics; blood pressure (BP); myocardial ischemia; blood volume (BV).
HE INCIDENCE OF cardiac morbidity and
T mortality is high in patients treated with
hemodialysis (HD).1 Left ventricular hypertro-
phy, coronary artery disease, and decreased cap-
illary density in the myocardium make these
patients vulnerable to ischemic events.1,2 Interven-
tions causing changes in hemodynamics, such as
the HD procedure itself,3-10 might result in a
further imbalance between cardiac oxygen sup-
ply and demand and thus trigger cardiac events.
However, little is known about the effect of these
hemodynamic changes during HD on cardiac
oxygen supply and demand. Cardiac oxygen
demand might decrease during HD because of a
decrease in preload, but it also might increase
because of increasing heart rate and peripheral
resistance. The net effect on the balance between
cardiac oxygen supply and demand has only
been studied during HD sessions in which no
fluid was withdrawn from the patients.11,12 Be-
cause ultrafiltration (UF)-induced hypovolemia
is the main cause of hemodynamic changes dur-
ing HD,5 the balance between cardiac oxygen
supply and demand should be investigated in HD
sessions during which fluid is removed.
oxygen supply and cardiac oxygen demand dur-
ing isolated UF (iUF) and HD combined with UF
(HD ϩ UF).
PATIENTS AND METHODS
Patients
Measurements were performed in nine random chronic
HD patients (7 men, 2 women); age, 44 Ϯ 17 years; range,
19 to 70 years). Six subjects in whom finger pressure could
not be measured properly during HD were not entered into
the study. The patients had renal failure for 6.9 Ϯ 4.7 years
(range, 1 to 17 years). Seven patients were treated with
erythropoietin (average dose, 5,111 U/wk). Four patients
From the Department of Nephrology, General Internal
Medicine, and TNO-BMI, Academic Medical Center; Dialy-
sis Center Dianet; and the Laboratory for Physiology,
ICaR-VU, Free University, Amsterdam, The Netherlands.
Received June 22, 1999; accepted in revised form Novem-
ber 10, 1999.
Supported in part by grant no. NWO 902-18-307 from the
Netherlands Foundation for Scientific Research (W.J.W.B).
Address reprint requests to Willem Jan W. Bos, MD,
Department of Internal Medicine, Sint Antonius Hospital,
PO Box 2500, 3430 EM Nieuwegein, The Netherlands.
E-mail: internsecr@antonius.net
The objective of this study is to investigate the
net effect of UF and HD on cardiac oxygen
supply and demand. We estimated both cardiac
2000 by the National Kidney Foundation, Inc.
0272-6286/00/3505-0005$3.00/0
doi:10.1053/kd.2000.6377
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American Journal of Kidney Diseases, Vol 35, No 5 (May), 2000: pp 819-826
819

820
BOS ET AL
were treated with vasoactive substances (three patients,
␤-blocking agents on nondialysis days; three patients, cal-
cium antagonists; one patient, long-acting nitrates; one pa-
tient, angiotension-converting enzyme inhibitor; and one
patient, ␣-blocking agent). None of the patients had experi-
enced a myocardial infarction, had been treated for heart
failure, or had clinical signs of autonomic failure.
The protocol was approved by the Medical Ethics Commit-
tee of the Academic Medical Center of the University of
Amsterdam (The Netherlands). All participants gave in-
formed consent.
derived (TNO-BMI) changes in stroke volume (SV), cardiac
output (CO), and systemic vascular resistance (SVR).17,18
SV calculations were not individually calibrated with inva-
sive measurements. Therefore, relative changes from control
values are given for changes in SV, CO, and SVR. Model-
flow-derived changes in CO have been shown to follow
thermodilution CO, with a mean deviation of 2% and an SD
of 8% during cardiac surgery.17 In patients with septic shock,
a bias of Ϫ0.1 Ϯ 0.8 L/min was observed during a 2-day
experiment.18 These results were in part17 obtained in a
patient group with vascular disease. There are no specific
pathophysiological reasons to expect problems with the
ability of Modelflow to track differences in CO in patients
with end-stage renal disease (ESRD). Therefore, we do not
consider it necessary and ethically justified to perform
validation measurements requiring right-sided cardiac cath-
eterization in HD patients.
Procedure
Patients were dialyzed with an AK-100 (Gambro, Stock-
holm, Sweden) or Fresenius 4000 (Fresenius Medical Care,
Bad Homburg, Germany) using polysulfone or cellulose
triacetate membranes.
To estimate left ventricular oxygen supply and demand,
the diastolic pressure time index (DPTI) and the systolic
pressure time index (SPTI)19,20 were calculated from aortic
pressure waves.21 These aortic pressure waves were recon-
structed from finger pressure waves using a generalized
transfer function.22 The transfer function compensates for
the physiological wave distortion of pressure waves travel-
ing toward the periphery by attenuating high-frequency
components while slightly amplifying low-frequency com-
ponents. The present transfer function from finger to aorta
was developed in 10 patients by adding a brachial artery–
aorta transfer function to the previously published finger-to-
brachial-artery transfer function.23,24 As expected, the result-
ing transfer function closely resembles published transfer
functions from finger or radial artery to aorta, with a maxi-
mal attenuation at 4 Hz.22,25 To estimate the effect on cardiac
oxygen supply, the area under the diastolic part of the aortic
pressure curve was calculated (DPTI, measured in millime-
ters of mercury ϫ second).20 To estimate the effect on
cardiac oxygen demand, the area under the systolic part of
the aortic pressure curve was calculated (SPTI, in millime-
ters of mercury ϫ second).20 The balance between oxygen
supply and demand was expressed as DPTI/SPTI ra-
tio.11,12,20,21 For all parameters, the average value during
2-minute periods at t ϭ Ϫ10, 0, 30, 50, 80, 110, 140, 170,
200, and 230 minutes was calculated.
The first 10 minutes after starting the extracorporeal
circulation was used as a control period, during which no
fluid was withdrawn and dialysate flow was zero (t ϭ Ϫ10
to t ϭ 0). From 0 to 30 minutes, 500 mL was ultrafiltrated
(iUF). The next 20 minutes was used to study the effect of
vascular refill; again, no fluid was withdrawn and dialysate
flow remained zero. During the next 3 hours, patients were
treated with HD ϩ UF. UF was performed as needed to
achieve dry weight.
Dialysate temperature was set at 36°C. This low tempera-
ture was used to prevent hypotensive episodes. Dialysate
contained 32 or 35 mmol/L of bicarbonate, 1.5 mmol/L of
calcium, 138 mmol/L of sodium, and 2 mmol/L of potas-
sium. All subjects were in a semirecumbent position during
the entire procedure. No additional fluid infusions were
needed because no patient developed hypotension.
Measurements
Blood volume (BV) change and arterial oxygen saturation
(SaO ) were measured continuously with the Critline system
2
(In-Line Diagnostics, Riverdale, UT).13 Briefly, the instru-
ment uses optical techniques to measure the absorption and
scattering properties of red blood cells passing through the
extracorporeal circuit to determine hematocrit and SaO .
2
Changes in BV are calculated from changes in hematocrit.13
These indirect hematocrit measurements are in close agree-
ment with direct hematocrit measurements.13 The instrument
Statistics
provides 20-second averages of BV and SaO .
2
All parameters were tested to have a normal distribution.
Results are expressed as mean Ϯ SD. After a two-way
analysis of variance, paired t-tests were used with a Bonfer-
roni correction for multiple comparisons to test the signifi-
cance of changes during different procedures. Correlation
coefficients were calculated to establish the relationship
between changes in different parameters.
Blood pressure (BP) was measured continuously with
Portapres, a portable version of Finapres (TNO-BMI, Amster-
dam, The Netherlands),14,15 using the middle finger of the
nonfistula arm. Finger-pressure measurements have been
validated against invasive BP measurements in many stud-
ies,14 including studies of subjects with signs of atheroscle-
rotic vascular disease.16 All procedures were marked with an
electronic time marker.
RESULTS
Data Analysis
Dialysis
BP and time marker were analogue to digital (A/D)
converted with a sampling rate of 100 Hz and stored in a
computer. Beat-to-beat values of systolic, mean, and dia-
stolic pressure in millimeters of mercury and heart rate in
beats per minute were calculated, together with Modelflow-
During iUF, 500 mL of fluid was withdrawn in
all patients. During the subsequent 3-hour HD ϩ
UF, a further 1,544 Ϯ 663 mL of fluid was
withdrawn.

CARDIAC EFFECTS OF HD
821
BV
t ϭ 240; P ϭ NS). Also, the relative contribution
of the systolic and the diastolic periods to the
cycle length did not change significantly (sys-
tolic time, 37.4% Ϯ 4.7% at t ϭ 0 versus
37.0% Ϯ 4.0% at t ϭ 240; diastolic time,
62.6% Ϯ 4.7% at t ϭ 0 versus 63.0% Ϯ 4.0% at
t ϭ 240).
BV decreased by 4.0% Ϯ 1.8% during iUF
(P Ͻ 0.01). It tended to increase during the refill
phase (1.0% Ϯ 2.1%; increased in eight of nine
patients; P ϭ not significant [NS]) and de-
creased during HD ϩ UF by 7.3% Ϯ 3.3%
(P Ͻ 0.01; Table 1 and Fig 1).
Hemodynamics
Cardiac Oxygen Supply and Demand
The hemodynamic responses during iUF, re-
fill, and HD ϩ UF are shown in Table 1 and Fig
2. In short, during iUF, systolic BP did not
change and diastolic and mean BP increased by
11 Ϯ 7.4 and 11 Ϯ 8.4 mm Hg, respectively
(both P Ͻ 0.01). SV and CO decreased, whereas
SVR increased. No significant changes in hemo-
dynamic parameters occurred during the refill
phase. During HD ϩ UF, BP did not change
further. Heart rate increased, and SV and CO
decreased further. The ejection time decreased
from 302 Ϯ 29 to 261 Ϯ 40 ms (P Ͻ 0.01).
Diastolic time did not change significantly
(522 Ϯ 138 ms at t ϭ 0 versus 460 Ϯ 135 ms at
SaO did not change during the entire proce-
2
dure (Table 1). DPTI increased during iUF, did
not change during the refill phase, and decreased
during HD ϩ UF. SPTI increased during both
iUF and the refill phase. During HD ϩ UF, it
decreased significantly (Table 1). DPTI/SPTI ra-
tio, representing the balance between cardiac
oxygen supply and demand, did not change dur-
ing the three periods (Table 1). However, when
the results of the various phases are combined,
an improvement in DPTI/SPTI ratio by 0.14 Ϯ
0.16, or 8.8% Ϯ 7.8%, was found (P Ͻ 0.05;
Table 1 and Fig 3).
Table 1. Baseline Values and Changes During Different Procedures
Change During
Baseline
0 min
iUF
UF ϩ HD
0 v 30 min
50 v 230 min
Blood pressure (mm Hg)
Systolic
Mean
Diastolic
Pulse pressure
138 Ϯ 22.7
82 Ϯ 19.5
59 Ϯ 17.7
79 Ϯ 18.9
75 Ϯ 13.2
302 Ϯ 30.3
100
3 Ϯ 11.8
11 Ϯ 7.4*
11 Ϯ 6.7*
Ϫ8 Ϯ 11.7
Ϫ1 Ϯ 4.6
3 Ϯ 7.8
Ϫ14 Ϯ 11.0*
Ϫ13 Ϯ 13.7†
33 Ϯ 27.9*
Ϫ4.0 Ϯ 1.8*
Ϫ13 Ϯ 23.7
Ϫ9 Ϯ 16.2
Ϫ3 Ϯ 12.9
Ϫ9 Ϯ 17.0
14 Ϯ 11.7*
Ϫ51 Ϯ 25.5*
Ϫ23 Ϯ 20.8†
Ϫ13 Ϯ 16.0†
10 Ϯ 38.7
Heart rate (beats/min)
Ejection time (ms)
Stroke volume (%)
Cardiac output (%)
SVR (%)
Blood volume (% change)
Cardiac oxygen supply
DPTI (mm Hg · s)
Oxygen saturation (%)
Cardiac oxygen demand
SPTI (mm Hg · s)
Supply/demand
DPTI/SPTI
100
100
100
Ϫ7.3 Ϯ 3.3*
38 Ϯ 11.5
98 Ϯ 1.7
7 Ϯ 8.0†
0 Ϯ 0.7
Ϫ7 Ϯ 8.3†
0 Ϯ 1.3
30 Ϯ 7.3
3 Ϯ 2.3*
Ϫ8 Ϯ 6.1*
1.24 Ϯ 0.23
0.08 Ϯ 0.17
0.09 Ϯ 0.15
NOTE. Absolute values are given for blood pressure, heart rate, ejection time, DPTI, oxygen saturation, SPTI, and
DPTI/SPTI ratio. Stroke volume, cardiac output, systemic vascular resistance, and blood volume are presented as relative
changes from baseline values. Values expressed as mean Ϯ SD.
*P Ͻ 0.01 in paired t-test (time 30 versus time 0 and time 230 versus time 50).
†P Ͻ 0.05 in paired t-test (time 30 versus time 0 and time 230 versus time 50).

822
BOS ET AL
Fig 1. Changes in blood
volume during isolated ultra-
filtration and hemodialysis
combined with ultrafiltration
are expressed as percentage
of change from baseline.
Data are presented as mean ؎
SD. Comparisons were made
against baseline values (t ؍ 0).
*P F 0.05. **P F 0.01 in
paired t-test.
Correlations
stolic and systolic periods. Diastolic BP in-
creased during iUF because of an increase in
SVR and remained stable thereafter, despite a
significant decrease in BV and CO. The increase
in BP during iUF might be caused by a decrease
in body temperature.3 Systolic pressure did not
change significantly during the procedure, but
pulse pressure decreased significantly because of
the decrease in SV, which in turn strongly corre-
lated with the decrease in BV. Because systolic
and diastolic time decreased at a similar rate, the
observed positive effect on DPTI/SPTI ratio can
mainly be attributed to the opposing changes in
diastolic and pulse pressures.
What is the clinical significance of an increase
in DPTI/SPTI ratio from 1.24 Ϯ 0.23 to 1.39 Ϯ
0.14? Estimation of DPTI, SPTI, and their ratio
yields indirect information about cardiac oxygen
supply and demand and has limitations.20 We
used these parameters because both cardiac oxy-
gen demand and supply can be estimated in a
noninvasive way. Measurement of oxygen satura-
tion in coronary arteries and veins in combina-
tion with coronary and ventricular pressure and
coronary flow measurements would yield supe-
rior information, but such measurements are not
feasible during HD. Generally, subendocardial
perfusion is considered to be hampered if DPTI/
SPTI ratio is less than 0.6.20
Changes in BV did not correlate with changes
in systolic (r2 ϭ 0.32; P ϭ NS), mean (r2 ϭ 0.07;
P ϭ NS), or diastolic pressure (r2 ϭ 0.34;
P ϭ NS). However, changes in pulse pressure
strongly correlated with changes in BV
(r2 ϭ 0.93; P Ͻ 0.01), as were changes in SV
and CO (r2 ϭ 0.97 and 0.90; P Ͻ 0.01). The
correlation between changes in BV and changes
in SV was also very strong in most individual
subjects (r2, 0.38 to 0.96; mean, 0.81; median,
0.85; Fig 4). Changes in DPTI were associated
with changes in both diastolic pressure (r2 ϭ 0.47;
P Ͻ 0.05) and duration of the diastolic period
(r2 ϭ 0.41; P Ͻ 0.05). Changes in SPTI were
equally well associated with changes in systolic
pressure (r2 ϭ 0.74; P Ͻ 0.01) and ejection time
(r2 ϭ 0.73; P Ͻ 0.01). Changes in DPTI and
SPTI were not related to changes in BV
(r2 ϭ 0.02 and 0.20, respectively; P ϭ NS).
DISCUSSION
In the present study, a slight improvement of
the balance between cardiac oxygen supply and
demand was observed. Because DPTI and SPTI
represent the area under the aortic pressure curve
during diastole and systole, respectively, they are
affected by changes in diastolic and systolic BP
and the length of the diastolic and systolic pe-
riod. In the present study, changes in DPTI and
SPTI depended on changes in both BP and dia-
In our studies, the values observed remained
much greater than this limit. However, we over-

CARDIAC EFFECTS OF HD
823
estimated DPTI and thus the DPTI/SPTI ratio
because left ventricular diastolic pressure, which
might be elevated in patients with ESRD because
of left ventricular hypertrophy and fluid over-
load, was not, as originally described by Buck-
berg et al,26,27 subtracted from the aortic pres-
sure. Furthermore, the critical DPTI/SPTI ratio is
likely to be much greater in subjects with ESRD
because the prevalence of left ventricular hyper-
trophy and coronary artery disease is very high.1
Their hearts are furthermore characterized by
extensive interstitial fibrosis.1 Coronary artery
stenoses decrease the actual perfusion pressure
in the coronary vascular bed,20 whereas left ven-
tricular hypertrophy and interstitial fibrosis in-
crease the resistance to flow while decreasing the
vasodilatory reserve.1,2 Thus, the supply of oxy-
gen might be diminished in patients with ESRD,
whereas the demand is generally increased be-
cause of left ventricular hypertrophy.2 Any change
in supply/demand ratio might thus be of clinical
significance in this population.
We chose to use a dialysate temperature of
36°C to prevent the occurrence of hypotensive
episodes.3 It should be realized that the use of
dialysate of a higher temperature might compro-
mise coronary perfusion because of hypotensive
episodes and temperature-induced vasodilation.
Because we did not observe hypotensive epi-
sodes in the present study, we were not able to
quantify their effect on the balance between
coronary oxygen supply and demand.
Questions can be raised concerning the reliabil-
ity of finger-pressure measurements, the recon-
struction of the aortic pressure wave, and Model-
flow calculations of SV, CO, and SVR. Therefore,
these items are discussed here. We had some
difficulty finding subjects in whom finger pres-
sure could adequately be measured during HD.
This could be caused by the effect of previous
arteriovenous fistulas on the nonfistula arm, pe-
ripheral vascular disease, or vasoconstriction dur-
ing HD. That a proper finger-pressure signal
could not be obtained during HD in all patients
might limit the clinical applicability of finger-
pressure measurements in dialysis populations.
We consider this technique mainly a noninvasive
research tool. Furthermore, it cannot be excluded
that a selection bias was introduced by perform-
ing the measurements only in selected subjects in
whom a proper finger-pressure signal could be
Fig 2. Blood pressure, pulse pressure (Pulse Pr),
heart rate (HR) and changes in stroke volume (SV),
cardiac output (CO), and systemic vascular resistance
(SVR) during isolated ultrafiltration and hemodialysis
combined with ultrafiltration. Changes in SV, CO, and
SVR are expressed as percentage of change from
baseline. Data are presented as mean ؎ SD. Compari-
sons were made against baseline values (t ؍ 0). *P F
0.05. **P F 0.01 in paired t-test.

824
BOS ET AL
Fig 3. The balance be-
tween oxygen supply and de-
mand during isolated ultrafil-
tration and hemodialysis
combined with ultrafiltration
is represented by DPTI/SPTI
ratio. Left ventricular oxygen
supply is estimated from
DPTI and oxygen demand
from SPTI. Data are pre-
sented as mean ؎ SD. Com-
parisons were made against
baseline values (t ؍ 0). *P F
0.05. **P F 0.01 in paired t-
test.
obtained. In dialysis patients in whom finger
pressures can be measured adequately, this finger
pressure might underestimate more centrally mea-
sured BPs, as in the elderly and subjects with
atherosclerotic disease.16,28 However, group aver-
age changes in these central pressures are tracked
reliably with finger-pressure measurements, even
in populations in which the absolute pressure
level at the finger is less than more centrally
measured pressures.14,16,28
cardiac supply and demand, we calculated DPTI
and SPTI from aortic pressure waves recon-
structed from finger-pressure measurements us-
ing a generalized waveform filter.21,22 On its way
to the periphery, especially the systolic part of
the pressure wave is amplified. Changes in heart
rate cause further changes in pressure amplifica-
tion,29 making calculations of SPTI in peripheral
pressure waves less meaningful. Generalized
waveform filters correct for such pulse-wave
amplifications.22-25
To estimate the effect of HD and UF on
Modelflow-derived calculations of changes in
CO have been validated against changes in ther-
modilution CO during cardiac surgery and treat-
ment in an intensive care unit (mean error,
2% Ϯ 8%).17,18 In this respect, the close correla-
tion between changes in BV and SV, measured
with two independent techniques, was a reassur-
ing finding. A correlation between BV and SV
has been predicted in computer models describ-
ing hemodynamic changes during HD30 and
described in studies in which CO was deter-
mined before and after HD.8,31 Our continuous
measurements of both BV and SV yield individual
BV-SV curves. The individual correlations were
strong, even though the slope of these Frank-
Starling–like curves differed between individu-
als. Differences in the slope might be attributed
to differences in cardiac contractility. However,
Fig 4. Group average changes in stroke volume at
all measurement points during the experiment are
closely related to changes in blood volume (r2 ؍ 0.97;
P F 0.01).

CARDIAC EFFECTS OF HD
825
13. Steuer RR, Harris DH, Conis JM: A new optical
technique for monitoring hematocrit and circulating blood
volume: Its application in renal dialysis. Dial Transplant
22:260-265, 1993
14. Imholz BPM, Wieling W, van Montfrans GA, Wesse-
ling KH: Fifteen years of experience with finger arterial
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vasc Res 38:605-616, 1998
15. Imholz BPM, Langewouters GJ, van Montfrans GA,
Parati G, van Goudoever J, Wesseling KH, Wieling W,
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finger pressure recording. Hypertension 21:65-73, 1993
16. Bos WJW, Imholz BPM, van Goudoever J, Wesseling
KH, van Montfrans GA: The reliability of noninvasive
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tens 5:529-535, 1995
17. Wesseling KH, Jansen JRC, Settels JR, Schreuder JJ:
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differences in venous compliance and heart rate
response might also contribute to differences in
the slope. Thus, the combined use of BV and SV
measurements might provide a useful noninva-
sive tool to study cardiac physiology during HD.
In conclusion, uncomplicated UF and HD in-
duce large changes in hemodynamics. These
changes cause a slight improvement in the bal-
ance between cardiac oxygen supply and de-
mand.
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