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Hypoxemia During Hemodialysis

Hypoxemia During Hemodialysis Abstract patients with chronic renal failure receiving hemodialysis experience hypoxemia during routine dialysis. First reported, to our knowledge, by Johnson et al1 in 1970, the fall in Pao2 is typically 10% to 20% of baseline. This decrease is usually well tolerated,2 but may be of critical importance in patients with limited pulmonary or cardiac reserve. We will review clinical evidence for pathophysiologic alterations—pulmonary and metabolic—that contribute to production of this hypoxemia. PHYSIOLOGIC APPROACH TO HYPOXEMIA Mechanisms of Arterial Hypoxemia Hypoxemia may result from five causes listed in the Table. Data needed to differentiate between these are shown. Categorization of hypoxemia physiologically aids in determining its cause, and provides a rational basis for choosing therapy. Alveolar Gas Equation and Arterial-Alveolar Po2 Difference In the Table, calculation of the arterial-alveolar PO2 difference (aADO2) provides the basis for distinguishing reduced fraction of oxygen in inspired air (FiO2) and hypoventilation References 1. Johnson NR, Bischel MD, Boylen CT, et al: Hypoxia and hyperventilation in chronic hemodialysis, abstracted. Clin Res 1970;19:145. 2. Brenner BM, Rector FC: Dialysis: Medical aspects , in The Kidney , ed 2. Philadelphia, WB Saunders Co, 1981, p 2497. 3. Bischel MD, Orrell FL, Scoles BG, et al: Effects of microemboli blood filtration during dialysis. Trans Am Soc Artif Intern Organs 1973;19:492-497.Crossref 4. Bischel MD, Scoles BG, Mohler JG: Evidence for pulmonary microembolization during hemodialysis. Chest 1975;67:335-337.Crossref 5. Aurigemma NM, Feldman NT, Gottlieb M, et al: Arterial oxygenation during hemodialysis. N Engl J Med 1977;297:871-873.Crossref 6. Kaplow LS, Goffinet JA: Profound neutropenia during early phase hemodialysis. JAMA 1968;203:1135-1137.Crossref 7. Toren M, Goffinet JA, Kaplow LS: Pulmonary bed sequestration of neutrophils during hemodialysis. Blood 1970;36:337-340. 8. Craddock PR, Fehr J, Brigham KL, et al: Complement- and leukocyte-mediated pulmonary dysfunction in hemodialysis. N Engl J Med 1977; 296:769-774.Crossref 9. Craddock PR, Fehr J, Dalmasso AP, et al: Hemodialysis leukopenia: Pulmonary vascular leukostasis resulting from complement activation by dialyzer cellophane membranes. J Clin Invest 1977;59:879-888.Crossref 10. Craddock PR, Hammerschmidt DE, Moldow CF, et al: Granulocyte aggregation as a manifestation of membrane interactions with complement: Possible role in leukocyte margination, microvascular occlusion, and endothelial damage. Semin Hematol 1979;16:140-147. 11. Jacob HS: Complement-induced vascular leukostasis: Its role in tissue injury. Arch Pathol Lab Med 1980;104:617-620. 12. Mahajan S, Gardiner H, Detar B, et al: Relationship between pulmonary function and hemodialysis-induced leukopenia? Trans Am Soc Artif Intern Organs 1977;23:411-414.Crossref 13. Graf H, Stummvoll HK, Haber P, et al: Pathophysiology of dialysis-related hypoxemia. Proc Eur Dial Transplant Assoc 1980;17:155-161. 14. Aljama P, Bird PAE, Ward MK, et al: Hemodialysis-induced leukopenia and activation of complement: Effects of different membranes. Proc Eur Dial Transplant Assoc 1978;15:144-153. 15. Jones RH, Broadfield JB, Parsons V: Arterial hypoxemia during hemodialysis for acute renal failure in mechanically ventilated patients: Observations and mechanisms. Clin Nephrol 1980;14:18-22. 16. Jacob AI, Gavellas G, Zarco R, et al: Leukopenia, hypoxia, and complement function with different hemodialysis membranes. Kidney Int 1980;18:505-509.Crossref 17. Dumler F, Levin NW: Leukopenia and hypoxemia: Unrelated effects of hemodialysis. Arch Intern Med 1979;139:1103-1106.Crossref 18. Hakim RM, Lowrie EG: Effect of dialyzer reuse on leukopenia, hypoxemia, and total hemolytic complement system. Trans Am Soc Artif Intern Organs 1980;26:159-164. 19. Raja R, Henriquez M, Kramer M, et al: Intradialytic hypotension: Role of osmolar changes and acetate influx. Trans Am Soc Artif Intern Organs 1979;25:419-421.Crossref 20. Brautbar N, Shinaberger JH, Miller JH, et al: Hemodialysis hypoxemia: Evaluation of mechanisms utilizing sequential ultrafiltration-dialysis. Nephron 1980;26:96-99.Crossref 21. Kraut J, Gafter U, Brautbar N, et al: Prevention of hypoxemia during dialysis by the use of sequential isolated ultrafiltration-diffusion dialysis with bicarbonate dialyzate. Clin Nephrol 1981;15:181-184. 22. Sherlock J, Ledwith J, Letteri J: Reflex hypoventilation and decreased arterial oxygen tension during ultrafiltration. Proc Clin Dial Transplant Forum 1978;8:250-253. 23. Torrance JD, Milne FJ, Hurwitz S, et al: Changes in oxygen delivery during hemodialysis. Clin Nephrol 1975;3:54-59. 24. Wathen RL, Ferris FZ, Nagar D, et al: An alternative explanation for dialysis-induced arterial hypoxemia. Kidney Int 1978;14:689. 25. Carlon GC, Campfield PB, Goldiner PL, et al: Hypoxemia during hemodialysis. Crit Care Med 1979;7:497-499.Crossref 26. Von Albertini B, Kirpalani A, Goldstein M, et al: Changes in pCO2 during and after hemodialysis. Proc Clin Dial Transplant Forum 1976; 6:199-202. 27. Tolchin N, Roberts JL, Lewis EJ: Respiratory gas exchange by high-efficiency hemodialyzers. Nephron 1978;21:137-145.Crossref 28. Graffe U, Milutinovich J, Follette WC, et al: Less dialysis-induced morbidity and vascular instability with bicarbonate in dialysate. Ann Intern Med 1978;88:332-336.Crossref 29. VanStone JC, Cook J: The effect of bicarbonate dialysate in stable chronic hemodialysis patients. Dialysis Transplant 1979;8:703-709. 30. Sherlock JE, Yoon Y, Ledwith JW, et al: Respiratory gas exchange during hemodialysis. Proc Clin Dial Transplant Forum 1972;2:171-174. 31. Sherlock JE, Ledwith J, Letteri J: Hypoventilation and hypoxemia during hemodialysis: Reflex respiration to removal CO2 across dialyzer. Trans Am Soc Artif Intern Organs 1977;23:406-410.Crossref 32. Nissenson AR, Patterson RW, Narins RG, et al: Dialysis-induced hypoxemia is due to increased O2 consumption and CO2 dialysance with normal lungs, abstracted. Kidney Int 1978;14:681. 33. Blumberg A, Keller G: Oxygen consumption during maintenance hemodialysis. Nephron 1979;23:276-281.Crossref 34. Wasserman K, Whipp BJ, Casburi R, et al: Carbon dioxide flow and exercise hyperpnea: Cause and effect. Am Rev Respir Dis 1977; 115( (suppl) ):225-237. 35. Kolobow T, Gattinoni L, Tomlinson TA, et al: Control of breathing using an extracorporeal membrane lung. Anesthesiology 1977;46:138-141.Crossref 36. Phillipson EA, Duffin J, Cooper JD: Critical dependence of respiratory rhythmicity on metabolic CO, load. J Appl Physiol 1981;50:45-54. 37. Dolan MJ, Whipp BJ, Davidson WD, et al: Hypopnea associated with acetate hemodialysis: Carbon dioxide flow-dependent ventilation. N Engl J Med 1981;305:72-75.Crossref 38. Patterson RW, Nissenson AR, Miller J, et al: Hypoxemia and pulmonary gas exchange during hemodialysis. J Appl Physiol 1981;50:259-264. 39. Tolchin N, Roberts JL, Hayashi J, et al: Metabolic consequences of high mass-transfer hemodialysis. Kidney Int 1977;11:366-378.Crossref 40. Kraut JA, Gafter U, Miller JH, et al: Prevention of arterial hypoxemia during hemodialysis by use of bicarbonate dialysate, abstracted. Kidney Int 1978;14:678. 41. Richards CJ, Newhouse CE, Freeman RM: Bicarbonate hemodialysis using a sorbent regenerative system. Clin Nephrol 1979;11:289-296. 42. Giorcelli G, Dalmasso F, Bruno M, et al: RDT with acetate-free bicarbonate buffered dialysis fluid: Long-term effects on lipid pattern, acid-base balance and oxygen delivery. Proc Eur Dial Transplant Assoc 1979;16:115-121. 43. Nissenson AR: Prevention of dialysis-induced hypoxemia by bicarbonate dialysis. Trans Am Soc Artif Intern Organs 1980;26:339-342. 44. Eiser AR, Jayamanne D, Koksong C, et al: Contrasting alterations in oxygen consumption and respiratory quotient during acetate and bicarbonate hemodialysis, abstracted. Am Soc Nephrol 1980;13:38. 45. Aizawa Y, Ohmori T, Imai K, et al: Depressant action acetate upon the human cardiovascular system. Clin Nephrol 1977;8:477-480. 46. Kirkendol PL, Devia CJ, Bower JD, et al: A comparison of the cardiovascular effects of sodium acetate, sodium bicarbonate, and other potential sources of fixed base in hemodialysate solutions. Trans Am Soc Artif Intern Organs 1977;23:399-405.Crossref 47. Valdivieso AJ, Perez GO, McDermott J, et al: Effect of hemodialysis on myocardial function as assessed by postural stress testing. Proc Clin Dial Transplant Forum 1979;9:87-92. 48. Chen TS, Friedman HS, Del Monte M, et al: Hemodynamic changes during dialysis. Proc Clin Dial Transplant Forum 1979;9:66-71. 49. Frohlich ED: Vascular effects of the Krebs intermediate metabolites. Am J Physiol 1965;208:149-153. 50. Oh MS, Uribarri JV, Del Monte ML, et al: Consumption CO2 in metabolism of acetate as an explanation for hypoventilation and hypoxemia during hemodialysis. Proc Clin Dial Transplant Forum 1979;9:226-229. 51. Desch G, Oules R, Mion C, et al: Plasma acetate levels during hemodialysis. Clin Chim Acta 1978;85:231-241.Crossref 52. Vreman HJ, Assomull VM, Kaiser BA, et al: Acetate metabolism and acid-base homeostasis during hemodialysis: Influence of dialyser efficiency and rate of acetate metabolism. Kidney Int 1980;18( (suppl) ):62-74. 53. Ikeda T, Hirasawa Y: Effect of acetate upon arterial gases. J Dial 1979;3:135-141. 54. Raja R, Kramer M, Rosenbaum JL, et al: Hemodialysis associated hypoxemia: Role of acetate and pH in etiology, abstracted. Am Soc Artif Intern Organs 1981;10:54. 55. Raja R, Kramer M, Rosenbaum JL, et al: Dialysis hypoxemia with varying dialyzers and dialysate: Role of acetate in etiology, abstracted. Am Soc Artif Intern Organs 1980;9:60. 56. Hakim RM, Lowrie EG: The relative effect of leukopenia and dialysate composition on the dialysis-associated hypoxemia, abstracted. Am Soc Nephrol 1980;13:40. 57. Shenouda AN, Yium JJ, Paty JC, et al: Effects of hemodialysis on blood oxygen, white blood count, platelets, and complements by two different membrane dialysers, abstracted. Am Soc Nephrol 1981;14:51. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

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American Medical Association
Copyright
Copyright © 1982 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1982.00340200118022
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Abstract

Abstract patients with chronic renal failure receiving hemodialysis experience hypoxemia during routine dialysis. First reported, to our knowledge, by Johnson et al1 in 1970, the fall in Pao2 is typically 10% to 20% of baseline. This decrease is usually well tolerated,2 but may be of critical importance in patients with limited pulmonary or cardiac reserve. We will review clinical evidence for pathophysiologic alterations—pulmonary and metabolic—that contribute to production of this hypoxemia. PHYSIOLOGIC APPROACH TO HYPOXEMIA Mechanisms of Arterial Hypoxemia Hypoxemia may result from five causes listed in the Table. Data needed to differentiate between these are shown. Categorization of hypoxemia physiologically aids in determining its cause, and provides a rational basis for choosing therapy. Alveolar Gas Equation and Arterial-Alveolar Po2 Difference In the Table, calculation of the arterial-alveolar PO2 difference (aADO2) provides the basis for distinguishing reduced fraction of oxygen in inspired air (FiO2) and hypoventilation References 1. Johnson NR, Bischel MD, Boylen CT, et al: Hypoxia and hyperventilation in chronic hemodialysis, abstracted. Clin Res 1970;19:145. 2. Brenner BM, Rector FC: Dialysis: Medical aspects , in The Kidney , ed 2. Philadelphia, WB Saunders Co, 1981, p 2497. 3. Bischel MD, Orrell FL, Scoles BG, et al: Effects of microemboli blood filtration during dialysis. Trans Am Soc Artif Intern Organs 1973;19:492-497.Crossref 4. Bischel MD, Scoles BG, Mohler JG: Evidence for pulmonary microembolization during hemodialysis. Chest 1975;67:335-337.Crossref 5. Aurigemma NM, Feldman NT, Gottlieb M, et al: Arterial oxygenation during hemodialysis. N Engl J Med 1977;297:871-873.Crossref 6. Kaplow LS, Goffinet JA: Profound neutropenia during early phase hemodialysis. JAMA 1968;203:1135-1137.Crossref 7. Toren M, Goffinet JA, Kaplow LS: Pulmonary bed sequestration of neutrophils during hemodialysis. Blood 1970;36:337-340. 8. Craddock PR, Fehr J, Brigham KL, et al: Complement- and leukocyte-mediated pulmonary dysfunction in hemodialysis. N Engl J Med 1977; 296:769-774.Crossref 9. Craddock PR, Fehr J, Dalmasso AP, et al: Hemodialysis leukopenia: Pulmonary vascular leukostasis resulting from complement activation by dialyzer cellophane membranes. J Clin Invest 1977;59:879-888.Crossref 10. Craddock PR, Hammerschmidt DE, Moldow CF, et al: Granulocyte aggregation as a manifestation of membrane interactions with complement: Possible role in leukocyte margination, microvascular occlusion, and endothelial damage. Semin Hematol 1979;16:140-147. 11. Jacob HS: Complement-induced vascular leukostasis: Its role in tissue injury. Arch Pathol Lab Med 1980;104:617-620. 12. Mahajan S, Gardiner H, Detar B, et al: Relationship between pulmonary function and hemodialysis-induced leukopenia? Trans Am Soc Artif Intern Organs 1977;23:411-414.Crossref 13. Graf H, Stummvoll HK, Haber P, et al: Pathophysiology of dialysis-related hypoxemia. Proc Eur Dial Transplant Assoc 1980;17:155-161. 14. Aljama P, Bird PAE, Ward MK, et al: Hemodialysis-induced leukopenia and activation of complement: Effects of different membranes. Proc Eur Dial Transplant Assoc 1978;15:144-153. 15. Jones RH, Broadfield JB, Parsons V: Arterial hypoxemia during hemodialysis for acute renal failure in mechanically ventilated patients: Observations and mechanisms. Clin Nephrol 1980;14:18-22. 16. Jacob AI, Gavellas G, Zarco R, et al: Leukopenia, hypoxia, and complement function with different hemodialysis membranes. Kidney Int 1980;18:505-509.Crossref 17. Dumler F, Levin NW: Leukopenia and hypoxemia: Unrelated effects of hemodialysis. Arch Intern Med 1979;139:1103-1106.Crossref 18. Hakim RM, Lowrie EG: Effect of dialyzer reuse on leukopenia, hypoxemia, and total hemolytic complement system. Trans Am Soc Artif Intern Organs 1980;26:159-164. 19. Raja R, Henriquez M, Kramer M, et al: Intradialytic hypotension: Role of osmolar changes and acetate influx. Trans Am Soc Artif Intern Organs 1979;25:419-421.Crossref 20. Brautbar N, Shinaberger JH, Miller JH, et al: Hemodialysis hypoxemia: Evaluation of mechanisms utilizing sequential ultrafiltration-dialysis. Nephron 1980;26:96-99.Crossref 21. Kraut J, Gafter U, Brautbar N, et al: Prevention of hypoxemia during dialysis by the use of sequential isolated ultrafiltration-diffusion dialysis with bicarbonate dialyzate. Clin Nephrol 1981;15:181-184. 22. Sherlock J, Ledwith J, Letteri J: Reflex hypoventilation and decreased arterial oxygen tension during ultrafiltration. Proc Clin Dial Transplant Forum 1978;8:250-253. 23. Torrance JD, Milne FJ, Hurwitz S, et al: Changes in oxygen delivery during hemodialysis. Clin Nephrol 1975;3:54-59. 24. Wathen RL, Ferris FZ, Nagar D, et al: An alternative explanation for dialysis-induced arterial hypoxemia. Kidney Int 1978;14:689. 25. Carlon GC, Campfield PB, Goldiner PL, et al: Hypoxemia during hemodialysis. Crit Care Med 1979;7:497-499.Crossref 26. Von Albertini B, Kirpalani A, Goldstein M, et al: Changes in pCO2 during and after hemodialysis. Proc Clin Dial Transplant Forum 1976; 6:199-202. 27. Tolchin N, Roberts JL, Lewis EJ: Respiratory gas exchange by high-efficiency hemodialyzers. Nephron 1978;21:137-145.Crossref 28. Graffe U, Milutinovich J, Follette WC, et al: Less dialysis-induced morbidity and vascular instability with bicarbonate in dialysate. Ann Intern Med 1978;88:332-336.Crossref 29. VanStone JC, Cook J: The effect of bicarbonate dialysate in stable chronic hemodialysis patients. Dialysis Transplant 1979;8:703-709. 30. Sherlock JE, Yoon Y, Ledwith JW, et al: Respiratory gas exchange during hemodialysis. Proc Clin Dial Transplant Forum 1972;2:171-174. 31. Sherlock JE, Ledwith J, Letteri J: Hypoventilation and hypoxemia during hemodialysis: Reflex respiration to removal CO2 across dialyzer. Trans Am Soc Artif Intern Organs 1977;23:406-410.Crossref 32. Nissenson AR, Patterson RW, Narins RG, et al: Dialysis-induced hypoxemia is due to increased O2 consumption and CO2 dialysance with normal lungs, abstracted. Kidney Int 1978;14:681. 33. Blumberg A, Keller G: Oxygen consumption during maintenance hemodialysis. Nephron 1979;23:276-281.Crossref 34. Wasserman K, Whipp BJ, Casburi R, et al: Carbon dioxide flow and exercise hyperpnea: Cause and effect. Am Rev Respir Dis 1977; 115( (suppl) ):225-237. 35. Kolobow T, Gattinoni L, Tomlinson TA, et al: Control of breathing using an extracorporeal membrane lung. Anesthesiology 1977;46:138-141.Crossref 36. Phillipson EA, Duffin J, Cooper JD: Critical dependence of respiratory rhythmicity on metabolic CO, load. J Appl Physiol 1981;50:45-54. 37. Dolan MJ, Whipp BJ, Davidson WD, et al: Hypopnea associated with acetate hemodialysis: Carbon dioxide flow-dependent ventilation. N Engl J Med 1981;305:72-75.Crossref 38. Patterson RW, Nissenson AR, Miller J, et al: Hypoxemia and pulmonary gas exchange during hemodialysis. J Appl Physiol 1981;50:259-264. 39. Tolchin N, Roberts JL, Hayashi J, et al: Metabolic consequences of high mass-transfer hemodialysis. Kidney Int 1977;11:366-378.Crossref 40. Kraut JA, Gafter U, Miller JH, et al: Prevention of arterial hypoxemia during hemodialysis by use of bicarbonate dialysate, abstracted. Kidney Int 1978;14:678. 41. Richards CJ, Newhouse CE, Freeman RM: Bicarbonate hemodialysis using a sorbent regenerative system. Clin Nephrol 1979;11:289-296. 42. Giorcelli G, Dalmasso F, Bruno M, et al: RDT with acetate-free bicarbonate buffered dialysis fluid: Long-term effects on lipid pattern, acid-base balance and oxygen delivery. Proc Eur Dial Transplant Assoc 1979;16:115-121. 43. Nissenson AR: Prevention of dialysis-induced hypoxemia by bicarbonate dialysis. Trans Am Soc Artif Intern Organs 1980;26:339-342. 44. Eiser AR, Jayamanne D, Koksong C, et al: Contrasting alterations in oxygen consumption and respiratory quotient during acetate and bicarbonate hemodialysis, abstracted. Am Soc Nephrol 1980;13:38. 45. Aizawa Y, Ohmori T, Imai K, et al: Depressant action acetate upon the human cardiovascular system. Clin Nephrol 1977;8:477-480. 46. Kirkendol PL, Devia CJ, Bower JD, et al: A comparison of the cardiovascular effects of sodium acetate, sodium bicarbonate, and other potential sources of fixed base in hemodialysate solutions. Trans Am Soc Artif Intern Organs 1977;23:399-405.Crossref 47. Valdivieso AJ, Perez GO, McDermott J, et al: Effect of hemodialysis on myocardial function as assessed by postural stress testing. Proc Clin Dial Transplant Forum 1979;9:87-92. 48. Chen TS, Friedman HS, Del Monte M, et al: Hemodynamic changes during dialysis. Proc Clin Dial Transplant Forum 1979;9:66-71. 49. Frohlich ED: Vascular effects of the Krebs intermediate metabolites. Am J Physiol 1965;208:149-153. 50. Oh MS, Uribarri JV, Del Monte ML, et al: Consumption CO2 in metabolism of acetate as an explanation for hypoventilation and hypoxemia during hemodialysis. Proc Clin Dial Transplant Forum 1979;9:226-229. 51. Desch G, Oules R, Mion C, et al: Plasma acetate levels during hemodialysis. Clin Chim Acta 1978;85:231-241.Crossref 52. Vreman HJ, Assomull VM, Kaiser BA, et al: Acetate metabolism and acid-base homeostasis during hemodialysis: Influence of dialyser efficiency and rate of acetate metabolism. Kidney Int 1980;18( (suppl) ):62-74. 53. Ikeda T, Hirasawa Y: Effect of acetate upon arterial gases. J Dial 1979;3:135-141. 54. Raja R, Kramer M, Rosenbaum JL, et al: Hemodialysis associated hypoxemia: Role of acetate and pH in etiology, abstracted. Am Soc Artif Intern Organs 1981;10:54. 55. Raja R, Kramer M, Rosenbaum JL, et al: Dialysis hypoxemia with varying dialyzers and dialysate: Role of acetate in etiology, abstracted. Am Soc Artif Intern Organs 1980;9:60. 56. Hakim RM, Lowrie EG: The relative effect of leukopenia and dialysate composition on the dialysis-associated hypoxemia, abstracted. Am Soc Nephrol 1980;13:40. 57. Shenouda AN, Yium JJ, Paty JC, et al: Effects of hemodialysis on blood oxygen, white blood count, platelets, and complements by two different membrane dialysers, abstracted. Am Soc Nephrol 1981;14:51.

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jul 1, 1982

References