Uh good evening professors doctors and colleagues from everywhere uh we are very honored today to have a very uh eminent Professor worldwide and the pioneer of dialysis and filtration Professor per Cano he has a very long list of introduction professor H H will be uh for sure introducing him I’m uh
Warm welcoming uh Professor pero from 3,000 doctors on my scientific group coming from uh the Middle East we have entire Egypt we have from Libya Tunisia Morocco Algeria we have as well from Asia we have Saudi Arabia om man KU bahin Kar Jordan so we have followers
From everywh uh on behalf of the 3,000 doctors I am really pleased to see see you here online and very heartfelt thankful for your time uh to join us and to learn from your side about the unveiling intradialytic hypotension on the other hand I’m very uh as well very
Honored to have Professor Dr Muhammad H the president of the afran and the past president of the Egyptian Society of nephology for sure Professor an hav is one of the pioneer of nephrology not only from Egypt but for the uh Middle East and all entire the world I I think
This will be a very uh tremendous uh talk we will have about 40 minutes then we can open the discussion for our colleagues to have the opportunity to ask uh one of the Pioneer in the field of nephology Professor Keno uh please Dr Hy I coming back later for the
Discussion thank you very much Professor hijam for giving us this uh wonderful night and uh giving us the chance to meet an eminent figure in the world of nephology Professor Bernard Cano Professor Bernard Cano is a Meritus professor of nephology Monier University School of Medicine in France uh he received in
2009 the uh highest French order of Merit leion donor from president sarui for his medical achievement uh again Professor uh Bernard Cano brings with him over uh 40 years of experience and Authority in the field of kidney disease and dialysis being in the editorial board of more than a dozen important academic
Journal and having more than 350 peer reviewed articles maybe the the one of the least latest of them was the convinced trial which demonstrated uh high do hdf and its uh effect on reduction of mortality and it was awaited for long period uh Professor Cano was the main participant
In the E European best practice uh guidelines uh for dialysis for nutrition for vascular AES and for many aspect of nephology uh he has been a former Chief medical officer of phinius in Europe Middle East and Africa and also uh clinical advis in the clinical Advisory
Board of invisus and of course he is a great uh asset uh for us to be uh tonight with us giving his expertise uh for all our nephology colleagues who definitely uh started to to put questions on the board even before starting yes so I leave the floor now for Professor Bernard
Canu okay good evening thank you very much particularly for Professor Isham and Professor Ani for the kind words this is too much this is my pleasure and certainly my privilege to share tonight with you some thought about the inic hypertension and certainly some practical aspect how to prevent antic
Hypotension the point is of course from my side tic hypotension is still very common in dasis as a side effect of diis and for the young fellow certainly they will be interested to know a little bit more about the TIC hypotension as a manifestation of hemodynamic instability
Because the term is used almost every day as soon as you enteris unit the first question will come to the to the physician or to the care to the caregivers is to understand why the patient get hypotensive during the DI deis and what is the impact of this I
Would say hypotension and this is what I would try to cover in a few minutes so unveiling inic hypotension as a manifestation of hemodynamic instability and the point is to make the link with what is what are the consequences which is know which is known as daes induced systemic stress
Because this is part of the consequence and certainly will affect I would say the outcome of the patient I will show you in a minute so what I will cover within uh within the next 40 minutes is some definition because tic hypotention I will show you
In a minute it’s not so easy if you ask 10 physician you will get 10 differences 10 different different answer about hypotension of course hypotension is hypotension but this is a very specific uh I would say understanding about antic hyp potential and what is a meaning and
What are the consequences so we need to make a link between the drop of the pressure and the consequences and I will show you some element second element would be the factors and all the pathopysiology links getting to the hypotension or intad deltic hemodynamic and stability the consequences and of course for the
The Physician and the caregivers is to act and to mitigate this tic hypotension in the take message so lot of elements so the first is a definition and of course you have to be aware that tic hypertension is a side effect of volume and sodium management but not only if we
Consider that 90 95% of the TIC hypotension is linked or is a consequence of the fluid and volume management there is some study showing that hypotension start even if you develop I isovic daes so that mean there is something and this is maybe 5 or 10% we don’t know exactly why but there
Is some I would say inra diotic hypotension which are not only mediated by the volume and the FL depression it could be some element who are linked to the removal of substances could be some interaction between the bio compatibility or bioincompatibility whatever but still I would say today the
TIC hypotension the side effect is for my side I would say 90 95% linked to the volume and sodium management so the first step is of course you know that in the dasis adequacy the first element is to make sure that you correct the food of a l of
The patient and this is what we call dry weight probing and this is the way there is no perfect definition about dry weight but the point is to make sure that you act on the patient to reduce the food volume to reduce the food overload and to maintain the pressure
Meaning that you can act actively on the F sodium and volume pressure management to restore what we call ostasis so the idea is to restore the homeostasis of the sodium water and volume and of course by the consequence the pressure and this is part of the activity which
Is is certainly the the main driving force for tic hyp potential and that was clearly shown uh two years ago by the cigo and they put I took this pictures from the cigo showing that the food management is really a sort of I would say Bal very delicate balance between
Hypovolemia hpia and volia so you need to restore this volic condition of the patient but of course you understand that due to the intermit of the treatment you have different phases and particularly in during the anttic phase the patient is getting volumic hypmic and then you get
Hypotension you get edema get dis and so on and so on and during the diation you just get hypmic so this is a sort of Tide I call it tide phenomenon where you get a tide up and a tide down pH phenomen Menon but Al together they
Create a lot of I would say hemodynamic effect or impact on the patient on one side you get hypmic this is hypertension cardiac remodeling left ventricular hypotrophy and on the left side hypmic this is hypotension and also sort of I will say ischemic head cells
That you get on the heart on the brain on the kidney on the gut on everything so you have different way to affect what we know as a diis induced systemic stress just to get in perspective what is what are the consequences now getting to the point of the
Definition if you look I just put in this cartoon four main definition I don’t want to go into detail from the kadok from the UK renal registry from European best practices in the final one is from kigo I don’t want to go into detail of this element but you see that
It could be a decrease of cyol blood pressure by more than 20 mm of mercury you get a symptom during HP potention in Europe we put decrease of 20 mm of mercury for the scoic or decrease of this mean arterial pressure plus minus symptoms who need how see
Nurse intervention so all together you get I would say some symptomatology from the GSD from the Japanese they said okay more than 30 mm Mercury so all the definition are right I don’t want to go into detail but what is important to remember is certainly what we learn and
This is part of the cigo any decrease of systolic blood pressure should be considered as a sort of danger for the patient now what is very dangerous for the patient is to get a very low soric BR pressure and the Nadia is less than 90 mm of
Mercury and the I I would say associated with symptoms or intervention I will show you in a minute why so just remember any decrease but the sever one is I would say considering scoic blood pressure less than 90 M mm of mercury and symptom with intervention just
Remember this number so whatever is the definition the other one now as I mentioned if you look on this what we call tic morbidity tic morbidity meaning not everything which is occurring during the diis or in a paridis Time tic hypotension is the most common symptom if you look on this UK study
Which was performed 10 or 12 years ago it’s not did not change really but if you see among the symptoms 80% 82% of the patient report fatigue after the DI decision but almost three quarters add some intrade detic hypotension cramps diseasess and so on and so on but tic
Hypertension this is one of the most common symptomatology or symptom occurring during the DI decision so if you consider that the quality of life of the Bion is a I would say a concern for improving the quality of care of your patient you have to consider tic
Hypotension as a main factors to correct so just remember that now the second aspect is of course to understand what are the factors and the pathophysiologic link to this hypotension uh I put in a very simple way and a sort of mechanistic approach what is reflecting hemodynamic stability during emodis so hemodynamic stability
Is a pressure that you get in the center of this triangle and of course as as soon as you start by the UT tritation this is a step one so as soon as you remove volume from the patient so utra fation volume reflected by utra fation weight then you
Create hypmic condition and this hypovolemic condition is reflecting a sort of balance between what you remove on one side and what the patient can bring back so what we call vascular refilling rate and you understand that the level of hypovolemia is just reflecting this imbalance between tritation rate and Vascular refering
Rate this is a very simple way to understand now based on this element of course there is sort of hemodynamic response and the hemodynamic response to hypmic or hypovolemia is of course to change element one is a cardiac output unfortunately the cardiac output does not increase dation only one aspect can
Increase this is Earth crate and I will show you in a m Earth rate is affected by the sympathetic or sympath parasympathetic imbalance so the cardiac output and the second element is vascular resistance So based on these two elements so cardiac output and Vascular resistance you get a sort of
Positive response to hypovolemic condition but these two elements are depending on the sympathetic nervous system and I will show you that a lot of patient onist fortunity they get I would say inbalance between the sympathetic and parasympathetic meaning that this way to adjust Earth rate and Vascular resistance is perfectly is not perfectly
Adapted and again depending on the vascular on the release of mediators such as the andine and so on and so on adrenaline or the camine you get I would say strong response on vascular resistance and cardiac output so just put in perspective and remember this very simple I would say mechanistic
Approach to understand hemodynamic stab and stability or stability during D session now the first step is of course as I mentioned hypo Mia and of course if you just look on the left side to the right you get a patient which is a total body water with a intracellular
Extracellular bmic condition the ultra fitration depending on the speed of the ultra fitration and the vascular refilling capacity you create this I would say fluid depletion so again I will show you in a minute in some patient the vascular feeling capacity is very high that could reflect tremendous
Fluid of a lot of the patient who can would reflect some entra I would say body permeability but it’s also in some patient very low I will show you in a minute and we can make a measurement during the DI decision based on what we call relative blood volume change this
Is a way to make an assessment about this refilling vascular capacity so you need to know what is a vascular feeling capacity for your patient because this is also an indicators what could be the maximum utr fitration or what would be the optimal utra fitration rate to
Prevent to move on a critical hypo volic condition I will show you so what is now what we call critical hypovolemia critical hypo volia this is a state where the contraction of the volia is so high that at the end the hemodynamic response of the patient is
Over past what does that mean if you get hypmic condition as I mentioned of course there is a way to increase to maintain the volia is to increase I would say theatr or to increase otic pressure so that mean the total protein concentration or to increase the
Tonicity I we come to this point with the nmia this is a way to prevent I would say tremendous I would say critical hyp ofia the second element is of course is to reduce ultra filtration rate I will come to this point because if you reduce ultra filtration rate then you
Facilitate the vascular refilling capacity or the vascular refilling rate and this is a very simple way that we know to reduce I would say utrai either you increase the treatment time I will show you in a minute or you reduce the utra the total utation develop in your patient increasing time
I know it’s really not appreciated by the PA meaning that if you are not able to reduce Tre intake salt intake then the only way is to increase frequency or to increase treatment time and the and the third aspect is of course to increase either the vascular resistance or the
Cardiac output in in other way to modify the sympathetic tone activity I will show you in a minute that we have some tools to act on this element and particularly on we discussed few minutes ago by the call if you just reduce the termal if you just create negative
Termal balance in your patient so creating I would say cool diate then you create sort of its stress reaction meaning that the patient will increase the vascular resistance I will show you in a minute so there is some way to act against this hypmic condition you you have that on on the slide
Now if you put in perspective what are the factors implicated in the TIC potential I just selected I would say two main group one on the on the top is a diis prescription this is very important to remember hypotension tic hypotension is certainly driven by your dietes
Prescription but the other one is a population or the patient profile because again as I mentioned some patient could tolerate could tolerate much more I would say free depletion as compared to the other one depending on the fys statute depending on the card condition depending on the sympathetic
Nerve system so two group of factors and that will show you in a minute if you look the Pres prescription related factors there is a lot of factors but I split in what I call measure factors and minor factors so major factors you see Ultra fitration volume this is certainly
If you don’t get get tion you will not observe a lot of hypertension treatment time diis modality and I will show you the impact on some modality the volume control or what we have inar on the dasis machine when we con act on the volume control of the patient temperature control and Di
It sodium this is the main factors who can affect or can be used to affect tic hypotension now other factors I put minor factors could be medication and we know that if you get I would say anti-hypertensive medication or if you get particularly beta blockers or calcium blockers or
Aits this is a way to prevent I would say the vascular adaptation D it potassium I did not mention calcium so there is a lot of factors exercise and again this is interesting I show I have seen few weeks ago a study showing that if you can exercise during the diis
Cycling for example this is a way to prevent hypotension so there is different other way but this is just to remember the main to the minor factors I just show this element so tic hypertension also this is interesting to know and this is is a almost 90 years old study so it’s not
Very new but still interesting in that case the study was a prospective study where they meas they make a measurement about the blood volume using at that time the quit liim system which is a way to make blood volume change during the diation and what they did they observe
In 60 prevalent patient and they monitors lot of di they clearly show that almost I would say 70% of the hypotension are coming in the the last quarter of the day decision so if you look and this is the start of the day decision and this is the end of the day
Decision you see that the frequency of course increase almost linearly or exponentially if you want but the majority of high potential are coming within the last quarter of the dation meaning that this is linked to the hypovolemic condition of the patient just remember second element is a patient
Related factors and again if you split in what I call major and minor factors one is the AG and of course if you are treating young patient and I know this is the case in Egypt you will get little bit less better hemodynamic response as compared to the elderly if you have the
Elderly patient 75 for example in France with a cardiac disease or diabetics this is the two main factors will affect the uh hemodynamic response to rra now if you combine elderly diabetics cardiac plus neuropathic patient then you get almost 90 99% chance to get hypotension and again there is some
Minor factors such as a comorbid condition vascular disease malnutrition hypoalbuminemia anemia medication so you have some factors but if you identify these factors you will realize that age and the diabetics or cardiac are the main cause of this hypertension and again coming from the same study this is
A the German study 19 years old this is interesting for you understand it on the uh y AIS you get the mean the percentage of relative blood volume change so if you start 100% And then you get down 10 20% 30% this is the decrease of relative blood volume
Change and this is the average each point is average plus a standard deviation so each point reflect one patient with a standard deviation and clearly you see what I said few minutes ago that you have at least three type of population if you move from the right
Right you get very sensitive patient as in this case this is a hmic condition create creating hypotension within less than 10% of the change in the blood volume they will get hypotension and if you look in the middle it’s about 10 to 15% meaning the critical hypo volic condition is about
10 to 15% and you have on the left side some patient who can tolerate up to 20 or 30 % relative blond volume change but of course if you forget what I said the average is 10 to 12% so if you don’t know what to do with your patient and if
You select I will come to this point blood volume I would say control by the machine you have to set a limit which is 10 to 15% over 10 to 15% it’s very risky for the Bion to make very lot very few patient will toate such a with say high depression now if
You get on the right side this is certainly cardiac patient or elderly patient or even patient where they are almost either volic when they come they come to the DI decision this is a I would say nice to know and this is some I would say phenotype of your patient to
Understand what is the maximum mation rate to be tolerated as I mentioned autonomic nervous system disorder and this is a very recent study you know two years already with a new device and this is device is not very complex they call that PSE sudoc scan this is a very simple device where you
Put on the finger or you put on the foot and this is a way to make a measurement about the choride exchange on the skin so it’s easy I don’t know I didn’t not any practices but reading the the the manuscript it looks very easy is
Not I would say invasive for the patient could be done very easily but what they did in this study this is a French study they identify that this son disia of hodis patient as shown here either from the upper arm or from the lefts is associated with a tremendous high risk
Of high potential you see almost 2.5 time or one time or three times and the risk of the cumulative risk of hrotic hypotension and of course this is over the time meaning that if the patient is identify with a sort of inbalance between the sympathetic versus parasympathetic and this is
Certainly very common is in this population you get tremendous risk of hypotension during the diis Deion so just remember and of course diabetics just fell in this category of patient third element is to understand what are the consequences of this high potential and this is known for almost I
Would say two or three decade I selected some study this is coming from Japan and that was one of the oldest study about 24 years or 20 no 20 20 years now show that intad deltic hypotension as soon as you get intad deltic hypotension you are affecting the mortality risk of the
Patient so higher is the TIC frequency and higher is the hypotension and higher is risk of death so this is a very important factors to understand so survivors or the patient who did not get any hypotention this is coming from Japan this is very interesting large
Numbers of patient but I will show you this is confirmed in a different study in particular way in us as soon as you get hypotension and more you get hypotensive and more you get frequent hypotension more is risk of death and particularly cardiovascular death this is one of the most popular
Study coming from flight I mentioned flight for the cigo and this is one of the earlier study showing in the lar thata set of patient this is coming from emo cemo study and a large care providers group in us I think it was Dita alog together if you look at
Numbers of patient if you split the patient according to the itra fitration rate and itra fitration rate is normalized by the body weight of the patient and hours of diation and few make very simple 10 10 to 13 more than 13 and then you look on the cardiovascular mortality and vas and
Orose mortality clearly you see that the threshold is around 10 as soon as you move over 10 and if you move to 13 you see the increase of aard ratio to get I we say risk for the cardiovascular mortality or to get all cause mortality so it’s clearly Associated this is a I
Would say retrospective study and of course this is particularly the risk if you get already some congestive art failure or without congestive AR failure but if you get I would say hypotension in a cardiac patient the risk is almost increased by 50% with 10 to 13 and
33% as soon as you move over 13 so clearly there is a sort of negative relationship between Lut tritation rate and the mortality and why the patient not dying and the same group show that it’s linked to the hypotension and this is numbers magic number I me mentioned in this
Cigo as soon as you get the hyp potentium size to leak less than 90 mm of mercury ason the mortality risk is increased by 50 to 60% same in this large quart of patient and you can imagine that numbers of patient is not small numbers but again
Showing almost the same so as soon as you get HP potential less than 90 mm of mercury then and not the first episode but more you get this frequent I would say potential and more you are affecting the mortality of the patient and the risk is increased by 40 to 60% relative
Risk and the drop of 20% is not significant the of 30% is toxicant significant kadok emo you see that is the only one and this is why n 90 mm Mery for siol drop has been retained as a sort of marus another point and this is part of
What I call hemodynamic stress and as I mention the patient on dasis is just on the cycling phenomenon and as I I mention this is what we call tide phenomenon the up and the down phenomenon up is reflected in this study almost 13 years or 14 years old interestingly they implanted in the
Dip a sensor in the ponary artery where the the monitors 24 hours for seven days and uh the the pressure we inside the the L inside the right atriums or right ventricle and the left ventricular pressure just to show this is the blue line I put here this is the normal
Arterial pressure in a normal subject if you see the patient they never get in this level they are very high or very low meaning that they get hyperic with high pressure in the Arial lungs or very low meaning that this this is reflecting I would say hyperic condition
Of the PA but not only as I mentioned on the hypo volic condition during the DI decision you get another stress which is hypmic and ischemic stress so the patient you have to understand that the patient on dasis it get from this hyperic to hypmic meaning that it get I
Would say mamic consequences and you know consequences on on the heart on the brain on the arteriopathy on the on the gut on the kidney I will show you in a minute so this is the reflecting what diis induc systematic stress is coming and just a summary this is a very simple
Cartoon to understand from the utraan through the TIC hypotension that are the consequences of what we call isic and organ damage for the cardiac system this is what we call cardiac stunning the brain and you know that there is a lot of cognitive dysfunction and also if
You make MRI you will see and that’s was done by minint showing that there is a lot of lesion coming in white matters great translocation arteriopathic inflammation liver abnormality and also we learn this is the best way to kill the kidy function since losing kidy function in disis is certainly reflected
The central deltic hypotension and repetitive ischemic and suit of the kidy so this is one aspect now we know the consequences yeah the idea is to try to understand how we Conn act and mitigate this inra potential just to make simple I put six type of actions that we can do from the
Left to the right and of course I will show from element one is the dise modality treatment time the blood volume monitoring or the blood volume management because it’s little bit more than monitoring teral balance sonum management and what is coming what we call predictive medicine but this is a
Little bit more for the futureistic approach so if you look and this is a study from locatell so if you can see there there is this modality that was again 14 years old this is a prospective study showing that inad deltic hypotension is less as compared to emodis and imop so you
Reduce by 50% the incident of hypotension with the modation as compared to thetion and as compared to EOD so very simple approach is of course to apply theod fetion to reduce int potenti tion now this is confirmed in a French study which was reported few years AG ago in a
Very specific population this is in the elderly and in this study the mean age as shown on the slide is 76 so we are not talking about young population we are talking of very old population showing that again imod F May Reduce by 11% any form of hypotension any
Asymptomatic hyp potential so this is one aspect second element of course it’s if you want to move and certainly more physiology this is a treatment time and I selected this study which is done by ganku few years ago showing that the incident of tic hypotension is inversely coaled with a treatment
Time what I put intensive emodis intensive emodis this is nocturnal this is more frequent or almost daily but as soon as you move to more frequent or longer dieses then you reduce tremendously the incident of hypotension so if you don’t want to be to put very complex element increase the
Treatment time or increase the frequency of your Digis or combine Modis plus utation and then you can reduce tic potential while you can create a free of your patient this is a recent study from the French group showing that daily so this is a short daily modalis this is a way to
Reduce tic HP potential and it’s not a magic treatment this is just a way by reducing withal rate and you can keep I would say low hypotension with this way of treating that has been confirmed by S study but this is coming from UK from Jeff and the minint groups showing that
Intensive Modis this is a way to reduce uto rate to reduce tic hypotension and to reduce cardiac stress so if you move if you look on the top so itra filtration volume this is a conventional emodis and this is intensive emod is with a in Center short daily nocturnal
Or daily omis you see that you can reduce clearly the UT tritation volume position and and if you reduce the UT tritation volume you reduce utra fitration rate and by the way you reduce cardiac stunning which is reflected by the the abnormality of the wall motion
Of the left ventricular so there is a nice relationship and if you combine utra fation rate and the number of cardiacs stun in the there is an inverse relationship so that mean you understand now that 10 m per kilo per hour this is a stral limit so if you get on the left
Side you reduce tremendously cardiac standing if you move on the right you increase tremendously cardiac stuning so this is clear we have the answer I tritation rate to I tritation rate associated with the cardiac study now the Third Way of acting is a volia it’s a critical volia as I
Mentioned so this is just summary of what happened during the DI decision so if you make a monitoring of the relative blood volume change with the di decision and you remember it would be less than 10% but some patient if you just follow over the 10% then there is and tic
Hypotension and then this is what we call crash the patients stop and you have to stop the utation and then if you stop the utation then you see the rebound of the curve meaning that this is reflecting the vascular refilling capacity but still this is a
Way where the patient is in the hypo in the critical hypmic condition and there is no way to adjust the hemodynamic response so if you control this element there is different way this is what we call feedback control so this is based on UT tritation if you set on your machine utation limit
To understand what is a critical volume and just to prevent to achieve this element study which was done in us not perfect but showing that at the end if you control the tritation you can reduce tremendously the hypotension during your D decision just acting on the volic control you can reduce tic
Hypotension now if you do that in a more scientific way and this is Again by Selby which is from minint group they make this study looking in the left ventricular left ventricular wall motion abnormalities so meaning the cardiac stunning and they compare the the biof feedback control BFD versus the standard
Modali is showing that with a bio feedback control you can reduce what they call Peak stress and Peak stress this is hypo volic condition plus the hypotension this is clear you can reduce this pig stress which is evaluated by the by the EOC cardiography But If You observe What’s happen now with the
Echocardiography in standard mod this you get I would say segment of of the heart who are affected by the cardiac stunning which is not the case with the bio feedback control so if you reduce the Pak stress then you can reduce tremendously cardiac stunning of your
Patient so this is a way to illustrate the topic and again if you look now what are the meta analysis I just Selected Few of this meta analysis just confirming that as soon as you act on the blood volume control there is a reduction of the incident of tic hyp
Potential so this is a blue diamond showing that all the study are very consistent to show that if you control the blood volume by this UT tritation you can reduce the incident of hypotension by 39% not only but there I did not show on the slide in the same study they show
That you can increase the po diis blood pressure by 14 mm of merro this is the way to act on the volume and the fourth this is a thermal balance if you perform a standard emodis with a 37 degrees or 35 37.5 degrees for the diate if you apply the
Default comparators on your diis you get what we call hyperic dasis and hymic dasis mean that the patient is gaining I would say calorie from the temperates and that was the main uh I would say aim of this major study in more than 20 years it it was convinced
That we had to develop at that time hypothermic dasis and hypothermic dasis the idea was to reduce to make sure that the end patient did not gain any calorie from the DI so as reducing temperature of the diit or adjusting the DI temperature to the patient temperat
Still and it show that clearly that if you develop hypmic dasis you get numbers of antic hypotension which is much more I would say higher as compared to hypothalmic that was the main and the first showing that hypo is was beneficial for the patient now the study have been
Developed and again from the UK group they make they made this study for one year so hypmic dasis and this is a prospective study developed in DB and Nottingham and for adapting the hypoid Isis is the concept was very simple by measuring the central temper the patient
And on the ear they just selected 05 degree less than the core temperature of the patient so easy to adjust and they perform for one year and what they observe in this patient if you develop this cool diis cool diis as I explained minus5 Dees as compared to the central
Temperatures you improve almost everything from the left ventricular the peak systolic stress the strain of the alt so all the hemodynamic parameters and the cardiac features are improving by the hypothermic so clearly showing that cooling diate has a beneficial effect on almost all parameters from the left ventricular to including Artic
Distance ability so that mean you affect the hemodynamic response for the patient and again if you look what is shown in the literatures metaanalysis again if you look on this large metanalysis the and I would say hypo hypothermic dasis reduce the incident of hypotension by 70% so this is clear now
We know that I would say hypothermic diis has a beneficial effect in reducing I would say hpo hypotension in a in a patient not only reduce hypotension but also tend to increase blood pressure at the end of the diis so this is a beneficial effect which is
Based on the physics of the D on the temp diate temperatures so just remember this element now if you follow the literates and you have seen this study by the Canadian group my temp study which was reported last year or two years ago now unfortunately this is what they call
Personalized cooler di it did not improve the long-term outcome of the patient that’s very strange but if you look the cardiovascular event and the cardiovascular with mortality was not changed and including the TIC hyp potential so if you believe me I said we have so many studies showing that H
Hypemic di is beneficial for the patient now if you look on real life in this Canadian study there is no beneficial effect or no cardioprotective effect now if you look inside the study and fortunately I don’t understand why the lset was not so critical about the study you have to understand that the
Measurement of the pressure was not collected by each D decision it was just on the selection of centers and the random the randomly selected centers and randomly selected inside the center the Bion where they make measurement of of the temp the blood pressure of the patient so I don’t understand but this
Is something which is from the methodological aspect very critical okay this is fact I cannot make any more comment and the last not the last but the fifth point is a sodium and sodium management is certainly something we have to consider much more I would say
In the FES now if you look on this study the idea is just to understand how the sodium management could be done and the sodium management of course is not only the weight loss tion but could be diate sodium concentration in this study the idea was to compare the sodium management which
Is provided by the machine two I would say Two element one is the ultra filtration and the regular emodis so the idea is of course if you select a machine and you select what we call iSonic condition meaning that you set the disis machine to make
Sure that the D sodium is aligned to the D sodium to the patient sodium this is a condition which is developed by the machine and then you compare to isolated tritation and you know that isolated tritation this is the best way to develop iSonic I would say removal of
Volume and then in this randomized studies they just compare isolated to ISO lmic condition as shown the the module from the machine is following perfectly what is the isolated and then after 90 minutes you restart the dig on the regular way and at the end you look what is the impact
On sodium on the plasma sodium and sodium Mass valal but still what is shown is of course if you are using on sodium control module inod di this machine you can achieve the equivalent of isolated dation so what are the beneficial effect now of making isonomic dases as compared to standard I would
Say diate sodium concentration one this is to reduce I would say plasma sodium concentration change or tonicity change and if you reduce tonicity change over the time time this is shown by the shrinking of this pre this sodium concentration this is a way to explain or reduce CST because the tonicity this
Is a way to stimulate the CST so by reducing this tonicity fluctuation during the diis then you modulate the C and then next you reduce the CST and then you reduce anti dietic weight gain so this is a way to understand what why it’s beneficial such a study has been
Performed recently by Madel in Spain where implemented such a with interesting study showing that playing with a regular machine and moving with a new machine with a fixed sodium control fixed sodium diate and I would say viable sodium concentration by the sodium control module and moving to iSonic condition
Clearly show that over the time the diate conductivity is reduced and then the sodium plasma concentration tend to reduce as I sh then you control the sodium mass balance you reduce antic way and you reduce also the dietic symptomatology so showing that at the end moving to more physiologic iSonic diis is beneficial
For the patient this is a Spanish study it was shown in Italy few years AG so with the different Technologies this is not on the emod machine but this is H hf4 which is a Bel n metronic system showing that if you make this HF HFR equilibrium this is
ISonic condition you can preserve the blood pressure over the time during the diis so you prevent hypotension but again if you compare now the regular Hodes to this Ison condition symptomatic hypotension is reduced inad deltic symptom are reduced and nures intervention are reduced so that mean there is a beneficial effect to make
Isonomic condition and the last point which is the features but we don’t have a lot of information this is what we call predictive medicine if you get access to large data set of patient if you can monitor the patient over the time then you can anticipate what would be the
Best utra filtration rate what would be the best UT tritation profile the sodium concentration to prevent hypotension so that could be a new way I don’t want to see the next future immediate but certainly if you get access to this big data and if you can get access to this
Analytic system you can anticipate what would be the best for your patient this is shown by this large study or already in Us in New York where they show that they can anticipate what will be the TIC hypotension 15 to 75 minutes before the TIC hyp potential so they make a
Modeling so this is a machine learning with lot of training lot of data coming but if You observe if you look on the right side the observe prediction of tic hypotention and what is predicted it’s a linear system so they are very accurate in the prediction and the in this case
The TIC hypertension was 16% but they can anticipate uh almost immediately within 15 to six 75 minutes and then Define what are the main factors or can affect I would say the TIC hypotension n drop blood flow treatment time tritation and so on and so on so
They can anticipate and they can I would say predict what would be the TIC hypotention risk like we do for the forecasting in the in the Tre in the time so now just to get the take a meage I put on this uh graph the simulation of trtic incidence driven by
The dises and this is what we learn according to thetion rate from I would say 5 to 25 and this is the incident of I would say htic hypotension now if you play with the different tools as I mentioned you can reduce tremendously this incident as shown by the feedback
Control by the online by the isolated to AFF blood temperat so meaning we have way of acting to prevent antic hypertension but again we have to respect some physiologic rules if you move over 15 or 20 there is no way to make a pre a prevention of the antic
Hypotension so there are some limits you can reduce you can improve or you can reduce the TIC hypotension in some high risky patient with some limit and of course this is reflecting I would say what I said intensive hodis short hodis Ultra short hodis and compliant patient
So this is the way and then just to end this long talk this is a simulation of almost 60 years if you look on the incident of tic hyp potential in the past it was almost 75% or 70% of the diges at the time was acetate was a
Cellulos membrane and then we see Defender with see Improvement of synthetic membrane bicarbonate tritation tritation control and then you see that of course there is a reduction of the TIC hypotension incident still now we are around 15 10 to 15% certainly this is something which is background I’m not
Sure we can get lower than this element except if we accept to increase treatment time so we have come a long way and we have a little further to go to improve this tic H potential not to reduce this hemodynamic and stability and thank you for your kind attention very happy to
Answer your question if you have any question but I’m I’m sure you get a lot of question thank you very much thank you very much uh Professor Bernard for this very elegant presentation uh taking us all over many many years and the last uh the last slide showing the experience of maybe 70
Years of dialysis with hypotention thank you very much H I think uh we have so many questions now on the chat and being the the title of this meeting ask the experts so we we should concentrate sure I leave the floor for Dram to to start the question H thank you very much
Professor Cano we always learn from your side and your experiences uh and we have here some of the our colleagues are asking let let us start with M so what about the adma asymmetric dile arine it is a little uh in the literature I studied that carefully because asymmetric dile arine can induce
Very potent inhibitor of nitric oxide uh but little about its clearance I approach about 70% clearance in a single session of high flux DS yeah you’re right so now I don’t know I I think you’re right this is reflecting some endotelial dysfunctions this is a way to adjust the ano release
And the vascular resistant but there I don’t I did not see any study linking I would say the removal rate of the asymetric yes the and the vascular resistance or the hemodynamic stability or hemodynamic instability so this is a nice marker I agree there is a lot of
Other markers but the point is to make the link between the level of this reduction or the level of this asymmetric dagine and the hemodynamic stability so the points of course biomarkers is one aspect but linking to some I would say hemodynamic response this is a little bit more complex yes
Exactly that’s the point this is why I’m not relying too much on just on the biomarket and the physics is a little bit more easier in D to make this adjustment exactly but you are right you’re are right yes I got 70% reduction rate but on long standing uh scenarios for dialysis with
Hypotension needs more attention uh my second question about the refilling Lake we know that the refering rate is uh delayed for 30 minutes about 30 minutes and the intrac hypotension happened during the first hour is more critical and more uh catastrophic in the uh outcome yeah
So how we can improve the refilling rate and can we uh just the first our decrease the filtration rate yeah that’s a good point you have to be careful because I did not mention this element but if you get hypotension very severe hypotension within the 15 or
I would yes 30 minutes initial of the diis this this is not reflecting hypmic condition this isting something different I would say side effect which could be linked by anaphylactic reaction by whatever but this is not hypovolemic condition so as soon as a patient is feeling worse or he
Get hypotension or get a shock or or any symptomatology the point is to understand what is the link with the diis brain with a material with something which is affecting the patient not the hypo volic not the volic condition what I’m mentioning is the volic condition is occurring little bit
Less later during the diation and as you mentioned this is reflecting the re refilling capacity of the patient so refilling capacity we can act on this element I show some element and particularly by the position of the patient of course if you ding I’m not sure lot of PA are ding in
A sitting position if you are sitting in a in on the chair and if the legs are very low so you you have between 600 and 800 ml in the legs this is I would say the worst condition for ding the patient now if you just move in a lying position
Then you mobilized so meaning that for example just ding the patient in lying position in the bed is better than on the chair sure if you just put I would say bending on the legs with sort of compression I would see bandage then you can mobilize so this is a very simple
Way to understand that physics can facilitate R this is very simple one now if you play with the di s and it was in the in the past very popular to start Di deis with high sodium concentration in the diate so you create hyponic diate and you have high ultra filtration rate
So you have the profiling so if you increase the sodium concentration plus utation this is a way to facilitate refilling capacity in the beginning of the session but you have to be very careful because at the end of the D session you need to reduce this died
Sodium concentration to a lower level to end the diation with a sodium which is lower than the patient because if you keep this high sodium concentration the patient will get thirsty and it will increase weight gain during the next session so if you play with this profiling utra and sodium you need to
Respect the sodium mass balance and the F mass balance this is why I put this sodium management because if you play with the Sodium management you know exactly what is the sodium that you remove during the Dig so this is one aspect and one also aspect is playing with a hypothermic or
Cooling di it if you reduce cooling uh if you reduce temperatures of the diit by 05 maybe in Egypt you can reduce much more depending on the weather condition and temperature outside in France is difficult to move to move lower than 0.5° as from the central temperatures of the
Tempal tempic temperatures for the patient but maybe in Egypt if you get higher temperatures you you cool down the patient then by cooling down there is a way of creating sort of cool stress meaning that you increase the vascular resistance capacity so you in and by the
Way you refill the patient from the vas from the Venus system because the vascular contraction that you get is on the Aral side good for the pressure but if you get the same on the Venus side this is a way to increase refilling capacity so this is why the cooling dies
It has beneficial effect to the patient you act on the pressure on the outer side you are you act on the earth rate and you act on the venous Return of the patient so this is some I would say practical yeah some steps yes some yeah
Uh Professor s Kam do you have any comment or questions thank you Professor thank you Professor Hy and thank you so much Professor Bernard for this elegant presentation as usual uh if you allow me to ask one question regarding the issue or the other side or the other face of
The coin regarding the intad dialytic hyper tension rather than hypotension you know yeah it is a very challenging problem and up till now it is not solvable so my question divided into two parts number one uh from your own experience uh as most of the literature actually didn’t
Clarify this point from your own own experience uh what is the road map or the action plan to do with such b that’s number one number two nowadays um thinking to start a study uh using this hdf for such patient uh uh based on thetive issue that may be removing Evas
Constrictive X or Y ureic toxin by as a middle molecule I mean endine endline as one may improve this issue should I start this uh study or no need to start thank you so much yeah this is a very good question of course I was supposed
To talk about tic hypotension I was not talking about ey but still this is a very important question because if you look in the literature it’s between 15 to 20% of the patient who get this what we call paradoxical hypertension yeah because this is paradoxical hypertension is the
Hypertension which is uring during the dession and some time getting very high at the end of the dession so this is very par paradoxical because you you deplete the PA on one side and rather that getting hypotension you get this hypertension so there are a lot of
Hypothesis and there are a lot of way of acting on this element first you have to understand and the first step is to make sure that a patient is not freed overload or sodium overload this is very important because a lot of study have shown that if you
Use for example bio impedance or if you use langon if you use the inferior venac diameters there is or if you use biomarkers such as a BNP or NT Pro BNP lot of these hypertens paradoxical hypertensive patient get felone so the point is to make sure that you can
Deplete the patient this is one Element second element me is to act on the on the on the treating the patient on the diet sodium and the way of treating the patient so D it sodium in this case and that would be a nice way to implement this ISO nmic condition since
There is some reports already and I have seen last year at the ER in PR Clinic is a case report so it’s not huge say but that was a case of hypertension rical hypertension and they start treating the patient with isonomic condition with a sodium management and
They were able to deplete the patient and completely prevent this hyp this the occurrence of this paradoxically hypertension during the Digis so from my understanding I agree that maybe some vascular mediatus could be involved and doine or whatever but my suggestion would be to play on a sodium and to play
On a sodium in particularly tissue sodium not in the skin but the tissue sodium which is in the vascular Toth so if you are able to deplete the patient in a safe way you will see that his hypertension is reducing over the time so one aspect as I
Mentioned explore the F status of the patient then try to extend treatment time then put iSonic condition in your patient and then make mass balance of your patient in theum and if it’s not sufficient add a sort of isolated UT tritation session in between so the time
If you do three times a week you add one session of isolated the tritation in between or during the weekend if you want and you will see that over the time you can prevent this I would say paradoxic hypertension so this is very pragmatic approach nothing to do with I
Don’t want to say that there is no mediators but lot of study have shown that there is no increase of camine there is no increase of no adrenaline there is no increase of endo R in there is no increase of vasopressin so if you look on the mediat
You will be disappointed nothing really fit with this hypertension which is uring so whatever about what is the answer from the tion I’m not sure that theod per say would be sufficient I would recommend to make imod with eyesonic condition so the boss and playing with a f status of the patient
And sodium content of the patient so this is my my I would say recommendation a very simple one but check uh I think what he did here in PR there was a clinical case showing that it was reported as a sort of post poster presentation I was interested to see the
Case because that was the perfect answer to your question acting on the depletion and but acting with isolat toic condition to prevent this with a large tonicity change in the patient who create or stimulate Sur or stimulate a lot of how would say reaction mediators coming from from the vascular
System thank you so much thank you H Professor F shahen do you have any comments thank you very much uham and uh Professor brand is excellent talk my question probably just uh away from what we are speaking about intad dialytic patient if we compare the outcome of transplant of those patients
To the other patient which doesn’t have intradialytic hypertension because it is noted that some of those patients get hypo perfusion of the kidney post transplant and probably the outcome is is not good like the other SPS you are right you’re right this is I would say I I show you few study but
Clearly if you get this hypotension and more is I would say you are two level of this HP potention one is the high potential level per se less you get from less 90 mm of mercury this is a way to make an quantification about the tissue perfusion because if you get
Too low there is no more per tissue perfusion and the frequency and of course it’s not only based on one hypotension but if you look the study usually the same patient get I would say one or twice or three times during the dession so if you make a sum during the
Month and you see the frequency of hypotension and this is linked to the cardiovascular event or to cardiovascular mortality of the patient so the intensity of the hypotension and the frequency of this hypotension clearly and it has been shown now for I would say with the functional Imaging
MRI particularly that as soon as you get hypotension on the brain you get some abnormality on the white matter and this is linked to some clinical observation if you look this cognitive dysfunction after the DI lot of patient and particularly I was by the elderly patient if you just ask a patient very
Simple question and if you I don’t know if they do Sudoku or any cross words the speed they do initially has nothing to do with the speed they do at the end of the DI decision so cognitive dysfunction is very common in di patient and this is linked to the hypmic condition and
Particularly with hypotension so on the brain on the art I show this cardiac stunning there is a different abnormality on the on the kidney it has been shown that as soon as you get hypotension you get low perfusion so of course if you get this transplant if you
Have the patient with a kidy transplant but on the native kidy is already uh shown that the way to kill the kid function is hyp potential and the gut is also creating some ischemic I would say insult on the G and certainly there is translocation of bacteria this is
Associated so we have a lot of complete pictures we know that hypotension and more it frequent is associated with end organ damage from the brain from the heart from the kidney from the liver from the gut from and from the arteriopathic if you have a diabetic patient with some arteriopathy as soon
As they get hypotension hypotensive you will see the arteriopathy which is tremendously I would say aggravating over the time so and even if you get a silent arteriopathy during the DI session they will get see very painful and you will see the legion increasing so it’s a very clear that the diis indu
Systemic stress it’s a I would say a way to create a lot of comorbid condition in your patient so we need to do something thank you thank you very thank you very much Professor f and Prof perard we will have some question I I know that you are
Tired enough but I will have just AIC uh messages I will answer some of them just to have a breath uh one of our colleague ABD Hamid is asking about midin I know that this is the last line of treatment but he is asking uh is it have a
Portality or not highest mortality or not so the midle drain was very popular in a few I don’t know 10 or 15 20 years ago it’s not it’s not I would say a lot of substances have been tested but at the end they did not bring any beneficial
Effect to the patient so you need to tackle what is the cause of the hypotension and not trying to break to give mid drain yes yeah to Mid yeah don’t don’t jump to midin you have to follow the procedure as Professor Cano said that we have this is midin is the last
And every step I think not all patient will need uh another question is saying about uh eating uh definitely eating will have spankin pressure blood flow will increase 30% and uh for sure you can use the glucose containing dine yeah correct that’s a point I did not mention
But in some say specific patient particularly if you get this spanking flow yes 30% with some opy of the of the gut or the so the the me during the D session is not well tolerated and you get a splunking sequestration and then you get hypotension so we ask usually to have a
Meal before or after but it’s not recommended during the DI session you are right yeah thank you very much uh coming from AED is asking about rule of albumin infusion in case of hypo aloria definitely this will improve the anotic pressure and the feeling rate so if
Patient hyp what is the what is important is not to give aloine why his patient your patient is low in Alo you have to ask about inflammation malnutrition this important right that’s the point it’s albine of course it works because if you why but the point is to understand why
The alamine is not staying in the vascular system if you get inflame so what you albine you put in the patient is going to the intes shal and then will not stay inside the vascular system so this is you’re right the point is to understand why the PA is hypo almic we
Have to check that yes H from M K is asking about some patients complain of muscle cramps but did not develop severe intrac hypotension this is also an interesting point that could be reflecting I would say speed of the water or the flux of the water and the
Sodium so that could reflect and could be improved by the iso nmic dases as I mentioned so you have to make if you in if you look inside this m study initially is a patient who are complaining about the cramps and then when you put this isonomic condition
Almost the cramp disappeared so cramps is not only one factor it’s not only the sodium it’s not only the water fluxus could be the calcium the Magnesium everything but still as soon as you get cramps we know that for example changing the the sodium concentration will improve or reduce the cramp frequency so
ISonic condition is a nice way to prevent cramps if the paent is it is the key of it is the key iSonic is the key uh last couple of questions from ABD Hamid any dialysis prescription recommended during acute cardiac events like Mard for or coron artius
Graft yeah that’s the point this is the most difficult one I would say I will try to make a Stressless I would say condition diis so that mean I would try to make a very slow low tritation and to make sure that I will say moving from every from every day slow dieses
Slow fluxes slow ration so everything should be slow to prevent I would say the cardiac I would say aggravation if you want so and check as D potassium for sure it’s prefer three M Dil potassium would be good yeah uh and I did not mention but also in
This case yes sure I would recommend oxygen supplementation because this is a nice way to prevent I would say some hypoxemic condition in a patient so it’s easy to make a supplementation of oxygen in a cardiac patient and that will improve hemodynamic tolerance and certainly the cardiac system
Too h i I will choose the last uh questions uh there is no rule of el cartine for prevention of tic hypertension uh one last question is uh sometimes in some patients that they start to dialysis and this question coming from Mustafa uh sometimes patient start dialysis with systolic 90 mm Mercury and
They can tolerate ultra filtration yeah that’s the difference so if they start 90 mm of mercury that means they get the cardiac I would say failur so that mean there is a very poor cardiac condition so in this case I would try to understand why they get so hypotensive certainly this isoc
Cardiac condition and then of course this is difficult to die a patient but in that case the only way to make sure that they can be Deliz is to make sort of isolated utra fitration and then D diis without any utrition so if you dissociate you tritri and the dases in
The dases condition you can mix this but that would be a quite challenging condition yes qu very quite challenging uh it’s about one and a half hour I understand that we take a lot of time from your uh side but really can I ask a last question sure uh you know Professor
Bernard that nowadays regarding this shat GPT um programs uh that are invading the nephology that dialysis and the transplantation uh to to give answers uh by artificial intelligence instead of asking the doctors yeah and there are many many papers in the last American Society of nephrology
About the value of this shed GPT studies so what is your futuristic vision for this especially if we are going for more home dialysis because maybe at home dialysis you don’t you don’t don’t find a physician to ask so could chhat GPT be substitute of physician for those patients is my
Question it’s a fantastic question that’s a fantastic I would say we take all the night to try to answer I don’t have the precise answer I’m completely excited by this artificial intelligence who support the physician but again the physician and the caregivers and everything but I’m not sure artificial
Intelligence will replace the physician this is there is no way now to make interface with the phys with a patient to understand to make a screening what is wrong with a patient that makes sense because the chat GPT or any artificial intelligent could identify what is wrong
With the patient the feeling of the patient now to find a solution this is a different story I’m not sure that the chat GPT or any artificial intelligence will will find a way I show some element You can predict what will be the risk of hypertension you can yes yeah you can
Predict what would be the best Ultra fation or the best treatment schedule maybe you can predict what would be the treatment the best treatment for a patient with a specific profile age diabetics and so on and so on but still this is a support to the support decision making is not to replace
The decision of the physician so I think there is space for the physician the nurses technician to keep their own work no way I’m still confident keeping all them working thank you very much uh we will continue the chatting and question on the chat I understand that we are
247 uh on the WhatsApp group for the 3,000 doctors I’m I’m doing my best to answer answer all other questions and I keep Professor Dr Annie just after thanking deeply my friend and looking forward meeting you in February just to enjoying uh sometimes with you and I’ll
Keep Professor Dr Annie just to close the meeting thank you very much Professor hasham for this very nice night and thank you very much Professor Bernar Cano we don’t want the time to finish we we yes we still want more meet the experts for hypertension and for all the problems of
Dialysis and we we we expect more and more sessions of this type I think it was very good very interactive and futuristic also and uh I hope to see you in Cairo next months thank you very much all for the kind invitation and happy New Years enjoy happy New Year Professor
Thank you very much thank you very all professors who are attending thank you very much a night thank you byebye byebye bye
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Thanks professor ❤
Thanks professor