Supplementary Material for: Hemodynamic Response to Glucose-Insulin Infusion and Meals during Hemodialysis

<b><i>Introduction:</i></b> Intradialytic nutrition may improve nutritional status and reduce mortality in patients on maintenance hemodialysis (HD) but has been associated with adverse events, mainly hemodynamic instability. Some dialysis centers therefore restrict intradialytic meals. In 2 clinical studies, we investigated the effects of intradialytic glucose-insulin infusion (GII) and meal intake on blood pressure (BP), pulse wave velocity (PWV), pulse wave analysis (PWA), and cardiac output (CO). PWA yielded augmentation index standardized with heart rate 75 (AIx@HR75). <b><i>Methods:</i></b> In the GII study, 12 nondiabetic HD patients had BP, PWV, PWA, and CO measured during 3 HD sessions: standard HD, HD with glucose infusion, and HD with GII. In the Meal study, 12 nondiabetic patients had BP and PWA measured on 3 study days: meal alone (non-HD), meal and HD, 2 meals and HD. Twelve matched healthy controls completed the non-HD day. <b><i>Findings:</i></b> In the GII study, glucose or GII had no additional effects on hemodynamic parameters compared with standard HD. HD resulted in a decrease in systolic BP of 13%, in diastolic BP of 9%, in AIx@HR75 of 17%, and CO of 18%. PWV was reduced by only 5%. In the Meal study, a meal alone did not change BP, whereas the combined influence of HD and meal intake reduced systolic BP with 22% and diastolic BP with 19%. Furthermore, AIx@HR75 decreased by 37% on HD days and by 36% in controls, but was unaffected on non-HD days. <b><i>Discussion:</i></b> In the GII study, HD significantly reduced BP, AIx@75, and CO, whereas PWV remained almost constant. No additional effects were observed by concomitant GII during HD. BP reductions seemed larger in the Meal study compared with the GII study. Taken together, HD per se appears as the main discriminant for intradialytic hypotension but in hemodynamically unstable patients the timing and route of nutrition provision should be considered carefully.

<b><i>引言：</i></b> 透析中营养支持可改善维持性血液透析（maintenance hemodialysis, HD）患者的营养状况并降低死亡率，但也可能引发不良事件，主要为血流动力学不稳定。因此部分透析中心会限制患者在透析过程中进食。本研究通过两项临床研究，探讨了透析中葡萄糖-胰岛素输注（glucose-insulin infusion, GII）与进食对血压（blood pressure, BP）、脉搏波速度（pulse wave velocity, PWV）、脉搏波分析（pulse wave analysis, PWA）以及心输出量（cardiac output, CO）的影响。通过脉搏波分析（PWA）可获得心率75次/分时标准化的增强指数（AIx@HR75）。<b><i>方法：</i></b> 在GII输注研究中，12名非糖尿病血液透析患者在3次血液透析疗程中接受了血压、脉搏波速度、脉搏波分析以及心输出量的检测，这3次疗程分别为标准血液透析、单纯葡萄糖输注血液透析以及葡萄糖-胰岛素输注血液透析。在进食研究中，12名非糖尿病患者在3个研究访视中接受了血压与脉搏波分析检测，这3个访视分别为：单纯进食（非血液透析状态）、进食联合血液透析、两次进食联合血液透析。另有12名匹配的健康对照者完成了非血液透析状态的访视。<b><i>结果：</i></b> 在GII输注研究中，与标准血液透析相比，单纯葡萄糖输注或GII输注对血流动力学参数无额外影响。血液透析可使收缩压降低13%、舒张压降低9%、AIx@HR75降低17%，以及心输出量降低18%；脉搏波速度仅降低5%。在进食研究中，单纯进食不会改变血压，但血液透析与进食的联合作用可使收缩压降低22%、舒张压降低19%。此外，AIx@HR75在血液透析访视中降低37%，在健康对照者中降低36%，但在非血液透析访视中无明显变化。<b><i>讨论：</i></b> 在GII输注研究中，血液透析可显著降低血压、AIx@HR75以及心输出量，而脉搏波速度几乎无变化。血液透析期间联合GII输注未产生额外影响。进食研究中的血压降幅似乎大于GII输注研究。综合来看，血液透析本身是透析中低血压发生的主要诱因，但对于血流动力学不稳定的患者，应谨慎考量营养支持的时机与途径。