Alayoud et al.

Theoretical Biology and Medical Modelling 2012, 9:24

http://www.tbiomed.com/content/9/1/24

RESEARCH Open Access

A model to calculate cardiac output in

hemodialysis patients by thermodilution
Ahmed Alayoud*, Kawtar Hassani and Mohammed Benyahia

Abstract
The Blood Temperature Monitor module (BTM) is used to measure recirculation by thermodilution in dialysis.
Numerous studies have confirmed its interest in the measuring of the vascular access flow. In this letter we
describe a model to calculate cardiac output in dialysis by the BTM.
Keywords: Cardiac output, Dialysis, Thermodilution, Vascular access flow, Recirculation

The Blood Temperature Monitor module (BTM) is used difference of the fluid leaving (Cven) and entering (Cart)
to measure recirculation by thermodilution in dialysis. the tissue compartment [4]:
Numerous studies have confirmed its interest in the
measuring of the vascular access flow [1–3]. In this let- dCven
j ¼ V ¼ ðCven  Cart Þ  Qv ð1Þ
ter we describe a model to calculate cardiac output in dt
dialysis by the BTM.
The systemic (Qv) and the access (Qa) flows mix in the
The model is based on two principles:
heart. When solute is cleared from the access flow during
HD, this mixing reduces the solute concentration of the
1. The measurement of recirculation rate by the BTM
mixed arterial blood. Since Cart is reduced, the concentra-
is based on the Fick principle by changing dialysate
tion gradient which can be built up between the blood
temperature, which will change the venous blood
and the dialysate and therefore the concentration driving
temperature returning to the patient. A dilution
force to remove solute from the blood is also reduced.
method described and validated by Schneditz et al,
The amount of transfer j is equal to the removal of sol-
using the recirculation values obtained with the
ute from the vascular access which is determined by Ac-
haemodialysis (HD) lines in the normal (Rnl) and
cess clearance (Kac) multiplied by mixed arterial
reverse positions (Rinv), is used to separate the
concentration (Cart) [4]. Access clearance (Kac) is dialyzer
central cardiopulmonary component of recirculation
clearance (Kd) corrected for 'short loop' recirculation at
(CPR) from the recirculation fraction and to
the access site and, therefore, may be less than (Kd).
calculate vascular access flow [3].
(Kac) can be measured by ionic dialysance.
2. Removal of solute from the systemic tissue
compartment is equal to the removal of solute from dCven
the vascular access. j ¼ V : ¼ Kac:Cart ð2Þ
dt

The removal of solute [j = —V x (dCven/dt)] from the Combination of equation (1) with (2) yields:
systemic tissue compartment (V = urea distribution vol-

ume) is the product of the flow through the systemic tis- Kac
Cven ¼ 1 þ :Cart ð3Þ
sue compartment (Qv) multiplied by the concentration Qv

The recirculation rate (R) may be calcultaed according

the following equation:

* Correspondence: a_alayoud@yahoo.fr ðCven  Cart Þ

Service of Nephrology, Hemodialysis and Kidney Transplantation, Military R¼ ð4Þ
Hospital of Instruction, Mohammed V, Rabat 10000, Morocco ðCven  CssÞ

© 2012 Alayoud et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Alayoud et al. Theoretical Biology and Medical Modelling 2012, 9:24 Page 2 of 2
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(Css) is the concentration leaving the dialyzer: So cardiac output can be measured using the blood

 temperature sensor, BTM, incorporated into the dialysis
Kd
Css ¼ 1  :Cart ð5Þ machine according to blood flow, BTM recirculation
Qb with reverse and normal placement of blood lines, and
(Kd) is dialyzer clearance which takes no account of ionic dialysance. However the use of the BTM for the
the recirculation, and can be calculated using access measurement of cardiac output is not yet validated, des-
clearance (Kac) corrected for total measured recircula- pite an approach for calculating CO by this module has
tion and blood flow (Qb) [5]: already been advanced in 1999 by Schneditz [3]. This ap-
proach is different from that described in our model be-
1R cause it doesn’t take into account the access clearance
Kd ¼ Kac:   ð6Þ
1  R: 1 þ Kac (Kac). Thus by comparing the two approaches we found
Qb
that Schneider has neglected the ratio Kac/CO.
From equations 3 to 6 we deduce; In summary, like transonic system, the BTM thermodi-
  lution can be used in measurement of cardiac output in
1  Rð1 Kac
Qb haemodialysis patient without additional cost, and there-
Qv ¼  Qb ð7Þ fore could allow tracking of cardiac function in this pa-
R
tient cohort. However a clinical validation of this model
Cardiac output (CO) is the sum of systemic flow (Qv) by comparison with other reference methods will be
and access flow (Qa) [4]: needed.
CO ¼ Qv þ Qa Competing interest
The authors declare that they have no competing interests
Qa is calculated from both recirculation values, obtained
with the haemodialysis lines in the normal (Rnl) and re- Authors’ contributions
AA has defined the research theme, developed the model and wrote the
verse positions (Rinv) [3]. The measurement process starts paper. KH has been involved in revising the manuscript. MB has given final
from the production of a « temperature bolus » secondary approval of the version to be published. All authors read and approved the
to the self-limited decrease in the temperature of the dia- final manuscript.
lysis fluid. This thermal decrease is initially sensed by the Received: 21 February 2012 Accepted: 21 June 2012
temperature sensor of the venous line, and after traveling Published: 21 June 2012
through the cardiopulmonary circulation of the patient,
References
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in a normal configuration. The same procedure is method. Nefrologia 2008, 28(4):447–452.
3. Schneditz D, Wang E, Levin NW: Validation of Haemodilaysis Recirculation
repeated with HD lines in a reverse configuration. Qa is and Access Blood Flow Measured by Thermodilution. Nephrol Dial
calculated from both recirculation values using the follow- Transplant 1999, 14:376–383.
ing formula without considering the ultrafiltration: 4. Schneditz D, Kaufman AM, Polaschegg HD, et al: Cardiopulmonary
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ð1  Rinv Þð1  RnlÞ 5. Gotch FA: Models to predict recirculation and its effect on treatment time in
Qa ¼ :Qb single-needle dialysis. In: Ringoir S, Vanholder R, Ivanovich P, editors. First
ðRinv  RnlÞ International Symposium on Single-Needle Dialysis. Cleveland: ISAO Press;
1984:305.
Equation 7 became in the normal position of the
haemodialysis lines: doi:10.1186/1742-4682-9-24
Cite this article as: Alayoud et al.: A model to calculate cardiac output in
  hemodialysis patients by thermodilution. Theoretical Biology and Medical
1  Rnl:ð1 þ Kac
Qb
Modelling 2012 9:24.
Qv ¼  Qb ð8Þ
Rnl

Thus, CO can be rewritten in terms of familiar, meas-

urable variables:
0 0  11
ð 1  Rinv Þ: ð 1  Rnl Þ 1  Rnl: 1 þ Kac
Qb
CO ¼ Qb:@ þ@ AA
ðRinv  RnlÞ Rnl