title: Prevalence and risk factors of hypotension associated with preload-dependence during intermittent hemodialysis in critically ill patients.
abstract: BACKGROUND
  Hypotension is a frequent complication of intermittent hemodialysis (IHD) performed in intensive care units (ICUs). Passive leg raising (PLR) combined with continuous measurement of cardiac output is highly reliable to identify preload dependence, and may provide new insights into the mechanisms involved in IHD-related hypotension. The aim of this study was to assess prevalence and risk factors of preload dependence-related hypotension during IHD in the ICU.
  
  
  METHODS
  A single-center prospective observational study performed on ICU patients undergoing IHD for acute kidney injury and monitored with a PiCCO® device. Primary end points were the prevalence of hypotension (defined as a mean arterial pressure below 65 mm Hg) and hypotension associated with preload dependence. Preload dependence was assessed by the passive leg raising test, and considered present if the systolic ejection volume increased by at least 10% during the test, as assessed continuously by the PiCCO® device.
  
  
  RESULTS
  Forty-seven patients totaling 107 IHD sessions were included. Hypotension was observed in 61 IHD sessions (57%, CI95%: 47-66%) and was independently associated with inotrope administration, higher SOFA score, lower time lag between ICU admission and IHD session, and lower MAP at IHD session onset. Hypotension associated with preload dependence was observed in 19% (CI95%: 10-31%) of sessions with hypotension, and was associated with mechanical ventilation, lower SAPS II, higher pulmonary vascular permeability index (PVPI) and dialysate sodium concentration at IHD session onset. ROC curve analysis identified PVPI and mechanical ventilation as the only variables with significant diagnostic performance to predict hypotension associated with preload dependence (respective AUC: 0.68 (CI95%: 0.53-0.83) and 0.69 (CI95%: 0.54-0.85). A PVPI ≥ 1.6 at IHD session onset predicted occurrence of hypotension associated with preload dependence during IHD with a sensitivity of 91% (CI95%: 59-100%), and a specificity of 53% (CI95%: 42-63%).
  
  
  CONCLUSIONS
  The majority of hypotensive episodes occurring during intermittent hemodialysis are unrelated to preload dependence and should not necessarily lead to reduction of fluid removal by hemodialysis. However, high PVPI at IHD session onset and mechanical ventilation are risk factors of preload dependence-related hypotension, and should prompt reduction of planned fluid removal during the session, and/or an increase in session duration.
authors.affiliation: Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France. laurent.bitker@chu-lyon.fr.
authors.forename: Laurent
authors.initials: L
authors.lastname: Bitker
authors.affiliation: Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France. frederique.bayle@chu-lyon.fr.
authors.forename: Frédérique
authors.initials: F
authors.lastname: Bayle
authors.affiliation: Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France. hodane.yonis@chu-lyon.fr.|Faculté de médecine Lyon-Est, Université de Lyon, Université Lyon I, 92 Rue Pasteur, 69007, Lyon, France. hodane.yonis@chu-lyon.fr.
authors.forename: Hodane
authors.initials: H
authors.lastname: Yonis
authors.affiliation: Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France. florent.gobert@chu-lyon.fr.|Faculté de médecine Lyon-Est, Université de Lyon, Université Lyon I, 92 Rue Pasteur, 69007, Lyon, France. florent.gobert@chu-lyon.fr.
authors.forename: Florent
authors.initials: F
authors.lastname: Gobert
authors.affiliation: Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France. veronique.leray@chu-lyon.fr.
authors.forename: Véronique
authors.initials: V
authors.lastname: Leray
authors.affiliation: Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France. romain.tapponnier@chu-lyon.fr.
authors.forename: Romain
authors.initials: R
authors.lastname: Taponnier
authors.affiliation: Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France. sophie.debord@chu-lyon.fr.|Faculté de médecine Lyon-Est, Université de Lyon, Université Lyon I, 92 Rue Pasteur, 69007, Lyon, France. sophie.debord@chu-lyon.fr.
authors.forename: Sophie
authors.initials: S
authors.lastname: Debord
authors.affiliation: Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France. alina.stoian-cividjian@chu-lyon.fr.|Faculté de médecine Lyon-Est, Université de Lyon, Université Lyon I, 92 Rue Pasteur, 69007, Lyon, France. alina.stoian-cividjian@chu-lyon.fr.
authors.forename: Alina
authors.initials: A
authors.lastname: Stoian-Cividjian
authors.affiliation: Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France. claude.guerin@chu-lyon.fr.|Faculté de médecine Lyon-Est, Université de Lyon, Université Lyon I, 92 Rue Pasteur, 69007, Lyon, France. claude.guerin@chu-lyon.fr.|Institut Mondor de Recherche Biomédicale (IMRB), INSERM 955 Eq13, Faculté de Médecine de Créteil, 8, rue du Général Sarrail, 94010, Créteil, France. claude.guerin@chu-lyon.fr.
authors.forename: Claude
authors.initials: C
authors.lastname: Guérin
authors.affiliation: Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France. j-christophe.richard@chu-lyon.fr.|Faculté de médecine Lyon-Est, Université de Lyon, Université Lyon I, 92 Rue Pasteur, 69007, Lyon, France. j-christophe.richard@chu-lyon.fr.|CREATIS, CNRS UMR 5220, INSERM 1044, INSA-Lyon, Université Lyon 1, 7 avenue Jean Capelle, 69621, Villeurbanne, France. j-christophe.richard@chu-lyon.fr.
authors.forename: Jean-Christophe
authors.initials: JC
authors.lastname: Richard
mesh_terms: D058186:Acute Kidney Injury / Q000209:etiology / Q000401:mortality; D000368:Aged; D016638:Critical Illness / Q000628:therapy*; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007022:Hypotension / Q000209:etiology*; D008875:Middle Aged; D011446:Prospective Studies; D006435:Renal Dialysis / Q000009:adverse effects*; D017582:Renal Replacement Therapy / Q000009:adverse effects; D012307:Risk Factors