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

Introduction: 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). Methods: 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. Findings: 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. Discussion: 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.

引言：透析中营养支持可改善维持性血液透析（HD）患者的营养状况并降低死亡率，但可能引发不良事件，主要为血流动力学不稳定。因此部分透析中心会限制透析中进食。本研究通过两项临床试验，探究了透析中葡萄糖-胰岛素输注（GII）与进食对血压（BP）、脉搏波速度（PWV）、脉搏波分析（PWA）及心输出量（CO）的影响。其中脉搏波分析采用心率标准化为75次/分时的增强指数（AIx@HR75）作为观测指标。
方法：在GII实验中，12名非糖尿病维持性血液透析患者在3次血液透析过程中完成相关指标检测，分别为标准血液透析、单纯葡萄糖输注血液透析以及GII联合血液透析。在进食实验中，12名非糖尿病患者在3个研究日完成检测：仅进食（未行血液透析）、进食联合血液透析、2次进食联合血液透析。另有12名匹配的健康对照者完成了未行血液透析的对照日检测。
结果：在GII实验中，与标准血液透析相比，单纯葡萄糖输注或GII联合输注未对血流动力学参数产生额外影响。血液透析可使收缩压降低13%、舒张压降低9%、AIx@HR75降低17%，心输出量降低18%；而脉搏波速度仅降低5%。在进食实验中，单纯进食未对血压产生影响，但血液透析联合进食可使收缩压降低22%、舒张压降低19%。此外，在血液透析日，AIx@HR75分别下降37%（患者组）与36%（健康对照组），但在未行血液透析的日期无显著变化。
讨论：在GII实验中，血液透析本身可显著降低血压、AIx@HR75及心输出量，而脉搏波速度几乎无变化；透析期间联合GII未观察到额外效应。进食实验中的血压降幅似乎大于GII实验。综上，血液透析本身是透析中低血压的主要诱因，但对于血流动力学不稳定的患者，需谨慎考量营养支持的时机与途径。