Should The Perfusion Be Done Two Hours Before Or Two Hours After Hemodialysis?

When confusion comes, try to find more convenient skills and theoretical basis for clinical work, do not follow blindly, find a working method that suits you, and find a method that the dialysis room agrees with. Is blood perfusion in the first 2 hours or the last 2 hours of the dialysis process? Let's take a look at the summary below...

In the description of the installation, pre-filling and removal process of blood perfusion in the 2021 version of SOP[1], it is not difficult to conclude that perfusion is completed in the first two hours. (Of course, is it understood as the recommended operating method of SOP? Think about it again, I won't discuss and explain it too much here.)

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Is the perfusion device placed before or after the filter? There is no doubt: "Before the filter[2]".

The Shanghai Expert Consensus [2] also describes whether perfusion should be performed in the first half or the second half of dialysis:

First half of dialysis: Remove the HP device 2 to 2.5 hours after treatment (first combination treatment) and continue HD treatment;

Second half of dialysis: Install the HP device 2 to 2.5 hours before the end of HD treatment (second combination treatment) and then perform combination treatment.

Notes:

① During the first combination treatment, it is recommended not to perform ultrafiltration or to perform less ultrafiltration to prevent the occurrence of coagulation.

② The second combination treatment may increase the clearance rate of medium and large molecules and protein-bound toxins, but it will increase the risk of coagulation and induce hypotension. The clinical choice can be made according to the actual situation.

It is reported [2] that there is no significant difference in the removal effect of the two combination treatments on serum creatinine and urea nitrogen in MHD patients. The second combination treatment has a better removal effect on the patients' iPTH, fibroblast growth factor 23 (FGF-23), blood β2-MG, IL-1, IL-6 and TNF-α, and does not increase the occurrence of adverse events such as hypotension and coagulation.

Domestic scholars [3] found that without changing the pre-filling method of the perfusion device, starting the perfusion in the last 2 hours of dialysis has the following advantages:

The perfusion device has a longer soaking time in heparin saline, which has a better anticoagulant effect.

If the perfusion starts in the last 2 hours, if coagulation occurs, the patient's effective dialysis time will be longer than when the perfusion starts at the beginning.

The entire nursing operation time is relatively shortened, and the patient time is correspondingly reduced.

Reduce the amount of saline reinfusion

Scholars [4] also found through research that the incidence of hypotension and dialysis circuit coagulation in patients in the above-mentioned second combination method is significantly lower than that in the previous combination group (P<0.05, P<0.01), and the number of cases of allergic reactions and bleeding is lower. (More data is needed to prove)

Scholars [5] also found that the coagulation risk of the second combination method did not increase, the amount of saline used was reduced, the patient waiting time was shortened, and the work efficiency was improved.

In terms of treating patients' skin itching, research [6] also found that the second combination method is better than the first method, with better improvement in laboratory indicators and lower incidence of complications.

The latest study [7] also found that the efficacy of hemoperfusion 2 hours after hemodialysis is better than that of hemoperfusion 2 hours before hemodialysis. It can more efficiently remove medium- and large-molecular toxins in patients with end-stage renal disease and uremia. While improving the adequacy of hemodialysis, improving the micro-inflammatory state of uremia patients and long-term complications such as skin itching, it can also reduce the economic burden of patients, improve patients' subjective comfort and clinical nursing work efficiency, and better serve patients.

However, for patients with severe malnutrition, prone to hypotension and hypercoagulation, combined treatment should not choose hemodialysis combined with hemoperfusion treatment 2 hours after hemodialysis, so as to avoid complications such as hypotension and coagulation, which will affect the treatment effect.

In summary, in clinical practice, there are different opinions and views on the different times to install the perfusion device when blood perfusion is combined with hemodialysis treatment. Each has its own advantages and disadvantages. The work faced by blood purification personnel may not be stereotyped, or the operation is unified by the department. It is also necessary to choose which time period is more appropriate for perfusion based on the actual situation of the patient. It is not easy to tailor it to different people, and a large amount of reference information and overall evaluation need to be combined to make decisions.

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