The Role of Small-Molecule Removal in the Control of Treatment Morbidity with Hemodialysis and Hemofiltration

  • Stanley Shaldon


In 1976, it was suggested that the critical factor in maintaining the blood pressure during isolated ultrafiltration (UF) was the stability of the serum osmolality, and that by inference the high incidence of symptomatic hypotension seen with efficient dialysis was due primarily to large drops in the serum osmolality.(1) A consequence of this ingenious study, limited to one series of acute experiments in only six selected patients, was the birth of the “shifters” school. The “shifters” believe that dialysis hypotension is due to hypovolemia during UF. The hypovolemia is exaggerated by the passage of extracellular fluid into the cells at the same time as it is removed from the body. Their conclusions are based on imprecise space measurements, and their results are often dubious.(2,3) I have never believed in the “shifter” school and feel that Bergström and associates’ conclusions(1) could not apply in a chronic situation. To study this matter in more detail we selected six patients(4) with a high incidence of symptomatic hypotension (drop in mean arterial pressure of more than 20% together with a requirement for nursing attention ± fluid replacement) during conventional hemodialysis lasting 4 hr and employing a 1-m2 cuprophane dialyzer. The study was divided into three parts. Each part lasted for 1 month. During part 1, the dialysate flow rate (single pass) was 500 ml/min; in part 2, the dialysate flow rate was 300 ml/min; and in part 3, the dialysate flow rate was 100 ml/min. All other parameters were kept as near constant during all parts of the study.


Serum Urea Serum Osmolality Symptomatic Hypotension Urea Clearance Dialysate Flow Rate 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Bergström J, Asaba H, Fürst P, Oulès R: Dialysis, ultrafiltration and blood pressure. Proc Eur Dial Transpl Assoc 13:293, 1976.Google Scholar
  2. 2.
    Keshinah P, Cadwell K, Walker R, Shapiro F: Acid base changes in sequential therapy. Proc Clin Dial Transpl Forum 7:53, 1977.Google Scholar
  3. 3.
    Schuenemann B, Berghardt J, Falda Z, Jacob I, Kramer P, Kraft B, Quellhorst E: Reactions of blood pressure and body spaces to haemofiltration treatment. Tr Am Soc Artif Intern Organs 24:687, 1978.Google Scholar
  4. 4.
    Shaldon S, Deschodt G, Beau MC, Ramperez P, Mion C: The importance of serum osmotic changes in symptomatic hypotension during short hemodialysis. Proc Clin Dial Transpl Forum 8:184, 1978.Google Scholar
  5. 5.
    Wehle B, Asaba H, Castenfors J, Fürst P, Grann A, Gunnarsson S, Shaldon S, Bergström J: The influence of dialysis fluid composition on the blood pressure response during dialysis. Clin Nephrol 10:62, 1978.PubMedGoogle Scholar
  6. 6.
    Rosa AA, Fryd DS, Kjellstrand CM: Dialysis symptoms and stabilization in long term dialysis. Practical application of the CUSUM plot. Arch Intern Med 140:804, 1980.PubMedCrossRefGoogle Scholar
  7. 7.
    Quellhorst E, Ruger J, Doht B, Beckmann H, Jacob I, Kraft B, Mietzsch G, Scheler F: Treatment of chronic uraemia by an ultrafiltration kidney—first clinical experience. Proc Eur Dial Transpl Assoc 13:314, 1976.Google Scholar
  8. 8.
    Baldamus CA, Ernst W, Fassbinder W, Koch KM: Differing haemodynamic stability due to differing sympathetic response: Comparison of ultrafiltration, haemodialysis and hae-mofiltration. Proc Eur Dial Transpl Assoc 17:205, 1980.Google Scholar
  9. 9.
    Shaldon S, Beau MC, Deschodt G, Ramperez P, Mion C: Vascular stability during hemofiltration. Tr Am Soc Artif Intern Organs 26:391, 1980.Google Scholar
  10. 10.
    Wizeman V, Sychla M, Leber HW: Simultaneous hemofiltration/hemodialysis versus hemofiltration and hemodialysis: Hemodynamic parameters. Proc Eur Soc Artif Organs 7:143, 1980.Google Scholar
  11. 11.
    Quellhorst E, Schuenemann B, Hildebrand U, Falda Z: Response of the vascular system to different modi membranes of hemofiltration and hemodialysis. Proc Eur Dial Transpl Assoc 17:197, 1980.Google Scholar
  12. 12.
    Henderson LW, Beans E, Prestidge H, Ford CA, Colton C, Frigon R: Evaluation of hemofiltration membranes. Tr Am Soc Artif Intern Organs, 9:48, 1980 (abstract).Google Scholar
  13. 13.
    Gotch FA, Lam MA, Prowitt M, Keen M: Preliminary clinical results with sodium-volume modeling of hemodialysis therapy. Proc Clin Dial Transpl Forum 10:10–18, 1980.Google Scholar
  14. 14.
    Henderson LW, San Felippo ML, Stone RA: Blood pressure control with hemodiafiltration. 12th Annual Contractors Conference, AKCUP NIAAMDD, January 1979, NIH Publication No. 81-1979. Bethesda, Md, US Government Printing Office, 1981, p 112.Google Scholar
  15. 15.
    Schimtt G, Tobin JM, Flamenbaum W: Prostaglandin E (PGE) blood levels during hemodialysis (HD): Comparison of cellulosic (CL) and polyacrylonitrile (PAN) membranes, in: Book of Abstracts. American Society of Nephrology, Washington, November 1980, p 51A.Google Scholar

Copyright information

© Plenum Publishing Corporation 1985

Authors and Affiliations

  • Stanley Shaldon
    • 1
  1. 1.Department of NephrologyUniversity HospitalNîmes-MontpellierFrance

Personalised recommendations