Effect of ultrafiltration on cerebral small-vessel disease and related outcomes in hemodialysis

• Published in: Clinical kidney journal Vol. 16; no. 7; pp. 1139 - 1148
• Main Authors: Shi, Lin, Zheng, Ke, Qian, Yujun, Han, Fei, You, Hui, Yuan, Jing, Wang, Haiyun, Song, Dan, Zhang, Dingding, Feng, Feng, Zhu, Yicheng, Li, Xuemei
• Format: Journal Article
• Language: English
• Published: England Oxford University Press 01.07.2023
• Subjects: Brain damage; China; Diagnostic imaging; Health aspects; Hemodialysis; Mortality; Original; Prevalence studies (Epidemiology); China; hemodialysis; cognitive decline; ultrafiltration; cerebral small-vessel disease; all-cause mortality
• ISSN: 2048-8505; 2048-8513
• DOI: 10.1093/ckj/sfad042

ABSTRACT Background Increasing evidence suggests a high prevalence of cerebral small-vessel disease (CSVD) in hemodialysis patients. Variable ultrafiltration during hemodialysis may contribute to brain lesions by inducing hemodynamic instability. We aimed to investigate the effect of ultrafiltration on CSVD and relative outcome in this population. Methods In a prospective cohort of maintenance hemodialysis adults, three features of CSVD including cerebral microbleed (CMB), lacunae and white matter hyperintensity (WMH) were measured by brain magnetic resonance imaging. Ultrafiltration parameters included the difference between annual average ultrafiltration volume (UV, kg) and 3%–6% of dry weight (kg), respectively, and the percentage of UV to dry weight (UV/W). The effect of ultrafiltration on CSVD and the risk of cognitive decline were investigated by multivariate regression analysis. Cox proportional hazards model was used to assess mortality over 7 years of follow-up. Results In the 119 study subjects, the frequency of CMB, lacunae and WMH was 35.3%, 28.6% and 38.7%, respectively. All ultrafiltration parameters were associated with the risk of CSVD in the adjusted model. There was a 37%, 47% and 41% greater risk of CMB, lacunae, and WMH, respectively, per 1% increment of UV/W. Ultrafiltration showed different effects on different distributions of CSVD. Restricted cubic splines depicted a linear relationship between UV/W and the risk of CSVD. At follow-up, lacunae and WMH were associated with cognitive decline, CMB and lacunae were associated with all-cause mortality. Conclusions UV/W was associated with the risk of CSVD in hemodialysis. Reducing UV/W might protect hemodialysis patients from CSVD and subsequent cognitive decline and mortality. Lay Summary Previous studies have reported a high prevalence of cerebral small-vessel disease (CSVD) in maintenance hemodialysis patients. CSVD is associated with multiple adverse outcomes including stroke, cardiovascular events and cognitive impairment. Hemodynamic instability resulting from ultrafiltration is considered to cause brain lesions during hemodialysis. In this prospective cohort study, we aimed to explore the effect of ultrafiltration on three typical features of CSVD, including cerebral microbleed (CMB), lacunae and white matter hyperintensity (WMH) and related outcomes in maintenance hemodialysis patients. We found that ultrafiltration parameters were positively associated with increased risk of CSVD. Lacunae and WMH were associated with cognitive decline; CMB and lacunae were associated with all-cause mortality at follow-up. Our findings highlight the essential role of avoiding over-ultrafiltration to prevent CSVD in patients undergoing maintenance hemodialysis. CMB, lacunae and WMH could serve as potential imaging markers to evaluate different clinical outcomes in hemodialysis. Graphical Abstract Graphical Abstract