ORIGINAL ARTICLE ISRA MEDICAL JOURNAL | Volume 9 - Issue 6 | Nov - Dec 2017 Increasing Blood Flow Rate; A Tool To Improve Adequacy Of Dialysis Aurangzeb Afzal1, Maira Iqbal Malik2, Adnan Shabbir2 ABSTRACT OBJECTIVE: To assess the effect of increasing blood flow rate on the adequacy of dialysis, and to prove that increased blood flow can be helpful in achieving adequate dose of dialysis, in patients having low efficiency of dialysis . STUDY DESIGN: Quasi experimental study PLACE AND DURATION: At Dialysis unit of Lahore General Hospital over a period of 1 month from 28th January to 28th February 2017. METHODOLOGY: A total of 40 patients on regular hemodialysis participated in this study. Hemodialysis was performed at two different blood flow speeds 300 and 350 ml/min. Blood samples were obtained just before start and 45 minutes after completion of dialysis to measure urea levels. Urea Reduction Ratio (URR) was used as an index of dialysis dose and hence dialysis efficiency. RESULT: Increasing blood flow rate from 300 to 350ml/min has a significant impact on URR and hence on dialysis adequacy. It was observed that increasing blood flow rate from 300ml/min to 350ml/min raised URR from 53% to 60%. Marked statistical difference in URR between the two groups that is 7% was observed using the paired T-test. P value was 0.001 (<0.05). CONCLUSION: Increasing blood flow rate (BFR) has been successful in boosting effective dose of dialysis and is likely to prove beneficial for patients requiring hemodialysis. KEYWORDS: Hemodialysis, Adequacy, Blood Flow Rates, Low Efficiency, Urea reduction ratio. HOW TO CITE THIS: Afzal A, Malik MI, Shabbir A. Increasing Blood Flow Rate; A Tool To Improve Adequacy Of Dialysis. Isra Med J. 2017; 9(6): 399-401 This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. INTRODUCTION whereby waste and excess water are removed from the blood and is a cornerstone of renal replacement therapy. During Being a lifesaving procedure, adequate dialysis confers health hemodialysis, small solute particles are removed by diffusion in patients with end stage renal disease dependent on dialysis. whereas convection is involved in the removal of larger Patients with end stage kidney disease need dialysis for particles. Factors such as membrane thickness, temperature, survival.1 Adequate dialysis is essential to enhance quality of flow rate of blood and dialysate affect the process of diffusion.4 life and increase lifespan. Dialysis is thus targeted at decreasing A Urea Reduction Ratio (URR) of 65% or higher has been morbidity and prolonging life. Mortality and morbidity of proven to improve outcome in dialysis patients.5,6 Increase in patients can be decreased by effective hemodialysis2 and blood flow rate (BFR), dialysate flow rate, duration of dialysis when not effective, can lead to increased number of deaths. and use of high quality dialyzers are some of the methods that A study was performed by Sehgal and his colleagues where can increase URR7,8 but all these cannot be implemented due the cost of inadequate dialysis was assessed and a conclusion to economic barriers.6 Bearing this is mind and keeping the was drawn that ineffective dialysis led to prolonged hospital other factors constant, this study was planned and performed stay and increased treatment cost. Thus, decrease in expense to monitor the extent to which change in flow rate of blood of treatment and improvement in health of patients can be affected the process of diffusion and hence the urea reduction brought about by adequate dialysis.3 Dialysis is a process ratio (URR) which was used as a measure of dialysis dose.5,6 Urea level of blood before and after dialysis was used to 1. Head of Department of Nephrology, calculate URR. Dialysis duration cannot be always increased Lahore General Hospital. due to intolerance of patients. Use of advanced filters means 2. Post Graduate Resident increase in cost of procedure. Also, the outcome of increase in Department of Medicine dialysate flow rate is usually short lived. This study was thus Lahore General Hospital. carried out to monitor a variable that would be feasible to apply and would be more cost effective.7,8. Thus keeping the Correspondence to: other factors constant, it aimed at observing the improvement Dr. Aurangzeb Afzal in dialysis efficacy with increase in flow rate of blood (BFR). The Head of Department of Nephrology, objective of our study was to assess the effect of increasing Lahore General Hospital. blood flow rate on the adequacy of dialysis, and to prove that E-mail: [email protected] increased blood flow can be helpful in achieving adequate dose of dialysis, in patients having low efficiency of dialysis. Received for Publication: 26-04-17 Accepted for Publication: 04-10-17 399 Aurangzeb Afzal et al. ISRA MEDICAL JOURNAL | Volume 9 - Issue 6 | Nov - Dec 2017 METHODOLOGY was found between increased blood flow rate and increase in URR. If we compare mean URR between two groups it went This quasi experimental study was carried out over a period of from 0.53 (53%) at blood flow 300 to 0.60 (60%) by increasing 1 month (January 28th to February 28th 2017) at Dialysis Unit of blood flow to 350 ml/min (Table-II). P value was 0.001 (less Lahore General Hospital. A total of 40 patients (25 Males, 15 than 0.05). This increase in urr is very significant. Females) aged 18-65 on regular hemodialysis participated in the study. Complete information about the study was provided TABLE-I: FREQUENCY OF SEX AND BIOCHEMICAL PARAME- to all the patients and they were included only after their full TERS OF DIALYSIS PATIENTS INCLUDED IN THE STUDY (N=40) consent. None of the participant patients dropped out. Only Variable Frequency Percentage the patients who were registered with the dialysis unit, those having arterio-venous fistulas, on twice weekly maintenance Male 25 62.5% dialysis lasting for 4 hours each, dependent on dialysis for Female 15 37.5% more than a year and those who had ample tolerability to Hep B positive 3 7.5% dialysis were included in the study. Whereas patients with double lumen catheters, on emergency hemodialysis (not Hep C positive 18 45% maintenance) and hemodynamically unstable patients HTN 20 50% unable to tolerate high flow rates were not included in the DM 6 15% study. Age, weight, height and serum albumin level of all Blood Flow 300 40 100% the patients was noted down. Presence of co-morbidities such as diabetes mellitus, hypertension, chronic liver disease Blood Flow 350 40 100% (CLD) was also made note of from clinical record by a team TABLE-II: COMPARISON OF URR AT TWO DIFFERENT BLOOD member. The dialysis machines were checked for proper FLOW SPEEDS IN DIALYSIS PATIENTS (N=40) functioning. A Fresenius model 4008S dialysis machine was used for every patient. Data from each patient was collected GROUP STATISTICS in two parts. In the first session, blood flow rate was set at Std. Std. 300ml/min (group - 1) and then at 350ml/min (group - 2) in the Groups N Mean Devia- Error next session of dialysis. In every patient, blood samples were tion Mean taken right before and 45minutes after each dialysis session. Group-I 40 .53070 .082584 .013058 A team member was designated for sampling, delivering and URR collecting blood samples to laboratory. Urea level in blood Group-II 40 .60060 .057139 .009035 was measured and recorded each time. Validity of collected data was constantly checked. Urea Reduction Ratio (URR) was an index of dialysis dose and hence dialysis efficiency. In this study, dialysis adequacy was monitored at two separate blood flow speeds. It was calculated using the standard formula (pre. dialysis urea – post. dialysis urea /pre. dialysis urea x 100). Data Analysis: We statistically analyzed data from both groups to observe change in URR by changing blood flow using t-test. Body weight of all patients was recorded prior to and after dialysis. Patients were constantly monitored during each session for hemodynamic stability. The collected data was analyzed using the SPSS 23.0 software, t-test was used to compare data between two groups. P-value <0.05 was considered statistically significant. RESULTS FIGURE – 1: MEAN URR IN THE TWO STUDY GROUPS. (N=40) A total of 40 patients were included in the study. Regarding the gender distribution of patients in the group, 62.5% (N=25) DISCUSSION were men and 37.5% were women [Table - I]. The largest proportion (50%) was formed by people aged between 41-60 Comparing this data with analogous studies9-12, there was clear years of age and only 10% was formed by people of 60 years evidence that efficiency of dialysis in our center was not up to and above. Only 15% had a history of diabetes mellitus and 50% the mark but marked improvement was seen by increasing flow of the patients were hypertensive [Table I]. Results show that rate of blood during dialysis. Kim and his colleagues performed increasing blood flow rate has a significant impact on URR and a study and demonstrated that effectiveness of dialysis can hence on dialysis adequacy. Paired t test was used to compare be ameliorated by raising BFR by 15-20%.13 Renal failure and the data between two groups. Comparison was made between end stage renal disease are some of the most prevalent health mean URR of group 1(blood flow rate 300 ml/min) and group problems we are facing today.