We thank the dialysis staffs and members of the department of nephrology in Saitama medical center of Jichi Medical University. We would like to thank Editage (www.editage.com) for English language editing.

All participants provided written informed consent. The study was approved by the Institutional Review Board of the Saitama Medical Center, Jichi Medical University, Japan (RIN 15&#8211;104).
1. Device for the monitoring of rSO2
<ol>
	<li>Prepare a NIRS device for measuring tissue oxygenation. This device has four channels and can perform measurement in up to four organs at the same time.</li>
	<li>Prepare a measurement sensor for NIRS monitoring, to evaluate rSO2 value...

<ol>
	<li>Nishiyama, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Regional+cerebral+oxygen+saturation+monitoring+for+predicting+interventional+outcomes+in+patients+following+out-of-hospital+cardiac+arrest+of+presumed+cardiac+cause:+A+prospective,+observational,+multicentre+study.">Regional cerebral oxygen saturation monitoring for predicting interventional outcomes in patients following out-of-hospital cardiac arrest of presumed cardiac cause: A prospective, observational, multicentre study.</a> Resuscitation. 96, 135-141 (2015).</li><li>Kobayashi, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Factors+associated+with+a+low+initial+cerebral+oxygen+saturation+value+in+patients+undergoing+cardiac+surgery.">Factors associated with a low initial cerebral oxygen saturation value in patients undergoing cardiac surgery.</a> Journal of Artificial Organs. 20 (2), 110-116 (2017).</li><li>Cruz, S. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+novel+multimodal+computational+system+using+near-infrared+spectroscopy+predicts+the+need+for+ECMO+initiation+in+neonates+with+congenital+diaphragmatic+hernia.">A novel multimodal computational system using near-infrared spectroscopy predicts the need for ECMO initiation in neonates with congenital diaphragmatic hernia.</a> Journal of Pediatric Surgery. 53 (1), 152-158 (2018).</li><li>MacEwen, C., Sutherland, S., Daly, J., Pugh, C., Tarassenko, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Relationship+between+Hypotension+and+Cerebral+Ischemia+during+Hemodialysis.">Relationship between Hypotension and Cerebral Ischemia during Hemodialysis.</a> Journal of the American Socociety of Nephrology. 28 (8), 2511-2520 (2017).</li><li>Polinder-Bos, H. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Changes+in+cerebral+oxygenation+and+cerebral+blood+flow+during+hemodialysis+-+A+simultaneous+near-infrared+spectroscopy+and+positron+emission+tomography+study.">Changes in cerebral oxygenation and cerebral blood flow during hemodialysis - A simultaneous near-infrared spectroscopy and positron emission tomography study.</a> Journal of Cerebral Blood Flow &amp; Metablism. 40 (2), 328-340 (2020).</li><li>Ookawara, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Differences+in+tissue+oxygenation+and+changes+in+total+hemoglobin+signal+strength+in+the+brain,+liver,+and+lower-limb+muscle+during+hemodialysis.">Differences in tissue oxygenation and changes in total hemoglobin signal strength in the brain, liver, and lower-limb muscle during hemodialysis.</a> Journal of Artificial Organs. 21 (1), 86-93 (2018).</li><li>Malik, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Tissue+ischemia+worsens+during+hemodialysis+in+end-stage+renal+disease+patients.">Tissue ischemia worsens during hemodialysis in end-stage renal disease patients.</a> The Journal of Vascular Access. 18 (1), 47-51 (2017).</li><li>Ito, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cerebral+oxygenation+improvement+is+associated+with+hemoglobin+increase+after+hemodialysis+initiation.">Cerebral oxygenation improvement is associated with hemoglobin increase after hemodialysis initiation.</a> TheInternational Journal of Artificial Organs. , (2020).</li><li>Valerianova, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Factors+responsible+for+cerebral+hypoxia+in+hemodialysis+population.">Factors responsible for cerebral hypoxia in hemodialysis population.</a> Physiological Research. 68 (4), 651-658 (2019).</li><li>Ookawara, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Associations+of+cerebral+oxygenation+with+hemoglobin+levels+evaluated+by+near-infrared+spectroscopy+in+hemodialysis+patients.">Associations of cerebral oxygenation with hemoglobin levels evaluated by near-infrared spectroscopy in hemodialysis patients.</a> PLoS One. 15 (8), 0236720 (2020).</li><li>Kovarova, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Low+Cerebral+Oxygenation+Is+Associated+with+Cognitive+Impairment+in+Chronic+Hemodialysis+Patients.">Low Cerebral Oxygenation Is Associated with Cognitive Impairment in Chronic Hemodialysis Patients.</a> Nephron. 139 (2), 113-119 (2018).</li><li>Miyazawa, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Association+of+cerebral+oxygenation+with+estimated+glomerular+filtration+rate+and+cognitive+function+in+chronic+kidney+disease+patients+without+dialysis+therapy.">Association of cerebral oxygenation with estimated glomerular filtration rate and cognitive function in chronic kidney disease patients without dialysis therapy.</a> PLoS One. 13 (6), 0199366 (2018).</li><li>Locatelli, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Haemodialysis+with+on-line+monitoring+equipment:+tools+or+toys.">Haemodialysis with on-line monitoring equipment: tools or toys.</a> Nephrology Dialysis Transplantation. 20 (1), 22-33 (2005).</li><li>Cordtz, J., Olde, B., Solem, K., Ladefoged, S. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Central+venous+oxygen+saturation+and+thoracic+admittance+during+dialysis:+new+approaches+to+hemodynamic+monitoring.">Central venous oxygen saturation and thoracic admittance during dialysis: new approaches to hemodynamic monitoring.</a> Hemodialysis International. 12 (3), 369-377 (2008).</li><li>Kamijo, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Continuous+monitoring+of+blood+pressure+by+analyzing+the+blood+flow+sound+of+arteriovenous+fistula+in+hemodialysis+patients.">Continuous monitoring of blood pressure by analyzing the blood flow sound of arteriovenous fistula in hemodialysis patients.</a> Clinical and Experimental Nephrology. 22 (3), 677-683 (2018).</li><li>Ito, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Factors+affecting+cerebral+oxygenation+in+hemodialysis+patients:+cerebral+oxygenation+associates+with+pH,+hemodialysis+duration,+serum+albumin+concentration,+and+diabetes+mellitus.">Factors affecting cerebral oxygenation in hemodialysis patients: cerebral oxygenation associates with pH, hemodialysis duration, serum albumin concentration, and diabetes mellitus.</a> PLoS One. 10 (2), 0117474 (2015).</li><li>Imai, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Deterioration+of+Hepatic+Oxygenation+Precedes+an+Onset+of+Intradialytic+Hypotension+with+Little+Change+in+Blood+Volume+during+Hemodialysis.">Deterioration of Hepatic Oxygenation Precedes an Onset of Intradialytic Hypotension with Little Change in Blood Volume during Hemodialysis.</a> Blood Purification. 45 (4), 345-346 (2018).</li><li>Cho, A. R., Kwon, J. Y., Kim, C., Hong, J. M., Kang, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+sensor+location+on+regional+cerebral+oxygen+saturation+measured+by+INVOS+5100+in+on-pump+cardiac+surgery.">Effect of sensor location on regional cerebral oxygen saturation measured by INVOS 5100 in on-pump cardiac surgery.</a> Journal of Anesthesia. 31 (2), 178-184 (2017).</li><li>Ito, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Deterioration+of+cerebral+oxygenation+by+aortic+arch+calcification+progression+in+patients+undergoing+hemodialysis:+A+cross-sectional+study.">Deterioration of cerebral oxygenation by aortic arch calcification progression in patients undergoing hemodialysis: A cross-sectional study.</a> BioMed Research International. , 2852514 (2017).</li><li>Ito, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Blood+transfusion+during+haemodialysis+improves+systemic+tissue+oxygenation:+A+case+report.">Blood transfusion during haemodialysis improves systemic tissue oxygenation: A case report.</a> Nefrologia. 37 (4), 435-437 (2017).</li><li>Ito, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Improvement+of+bilateral+lower-limb+muscle+oxygenation+by+low-density+lipoprotein+apheresis+in+a+patient+with+peripheral+artery+disease+undergoing+hemodialysis.">Improvement of bilateral lower-limb muscle oxygenation by low-density lipoprotein apheresis in a patient with peripheral artery disease undergoing hemodialysis.</a> Nefrologia. 39 (1), 90-92 (2019).</li><li>Kitano, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Changes+in+tissue+oxygenation+in+response+to+sudden+intradialytic+hypotension.">Changes in tissue oxygenation in response to sudden intradialytic hypotension.</a> Journal of Artificial Organs. 23 (2), 187-190 (2020).</li><li>Lemmers, P. M. A., Toet, M. C., van Bel, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+patent+ductus+arteriosus+and+subsequent+therapy+with+indomethacin+on+cerebral+oxygenation+in+preterm+infants.">Impact of patent ductus arteriosus and subsequent therapy with indomethacin on cerebral oxygenation in preterm infants.</a> Pediatrics. 121, 142-147 (2008).</li><li>Ito, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sleep+apnea+syndrome+caused+lowering+of+cerebral+oxygenation+in+a+hemodialysis+patient:+a+case+report+and+literature+review.">Sleep apnea syndrome caused lowering of cerebral oxygenation in a hemodialysis patient: a case report and literature review.</a> Renal Replacement Therapy. 4, 54 (2018).</li><li>Minato, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Continuous+monitoring+of+changes+in+cerebral+oxygenation+during+hemodialysis+in+a+patient+with+acute+congestive+heart+failure.">Continuous monitoring of changes in cerebral oxygenation during hemodialysis in a patient with acute congestive heart failure.</a> Journal of Artificial Organs. , (2019).</li></ol>

No conflicts of interest.

NIRS monitoring has been mainly used to evaluate cerebral rSO2, especially in cardiovascular or cerebrovascular surgeries, which require extracorporeal circulation. During extracorporeal circulation including HD therapy, some organs could show relative ischemia7,17,18; however, it remains unclear whether tissue oxygenation becomes low or not. Muscle cramps or abdominal pain during HD could be one of the prodromal symp...

Near-infrared spectroscopy (NIRS) has been used to evaluate regional oxygen saturation (rSO2), a marker of tissue oxygenation, especially cerebral oxygenation in various clinical settings1,2,3 and has recently been applied to patients undergoing hemodialysis (HD)4,5,6,7,8,9,10,11. Cerebral rSO2 is reportedly associated with cognitive function in patients undergoing HD or those with non-dialyzed chronic kidney disease (CKD)11,12. However, thus far, the use of NIRS monitoring has been limited in patients with CKD.
As NIRS monitoring is real-time and noninvasive, we assessed its usefulness as a monitoring device in patients undergoing HD. Although NIRS is mainly used to measure cerebral rSO2, we also investigated rSO2 values in other organs during HD. Specifically, the rSO2 measurement sensors were attached to the forehead, the right hypochondrium and the lower legs to evaluate rSO2 in the brain, liver and lower muscles, respectively. The results showed that NIRS monitoring could be a new approach to clarify changes in organ oxygenation during HD or factors affecting tissue oxygenation in CKD patients.
To date, continuous monitoring was performed during HD, blood volume monitoring, central venous oxygen saturation, thoracic admittance and electronic stethoscope-guided estimated blood pressure (BP) in clinical settings13,14,15; however, there are limitations for the prediction of hypotension or the wide use of devices. In contrast, the new noninvasive approach here could provide real-time information on intradialytic oxygen dynamics in individual organs. Therefore, this monitoring method may allow the detection of transient organ ischemia in the early phases of intradialytic hypotension and may also permit the safe performance of HD. This article describes a protocol to measure tissue oxygenation represented by rSO2, as applied in patients undergoing HD.

<table>
	<tbody>
		<tr>
			<td>DBB-100NX</td>
			<td>Nikkiso</td>
			<td>DBB-100NX</td>
			<td>Dialysis machine</td>
		</tr>
		<tr>
			<td>INVOS 5100c</td>
			<td>Covidien Japan</td>
			<td>INVOSTM 5100c</td>
			<td>tissue oxygenation device</td>
		</tr>
		<tr>
			<td>SOMASENSER</td>
			<td>Covidien Japan</td>
			<td>CV-SAFB-SM/INTL</td>
			<td>NIRS sensor</td>
		</tr>
	</tbody>
</table>

measurement of tissue oxygenation using near-infrared spectroscopy in patients undergoing hemodialysis

Near-infrared spectroscopy (NIRS) has recently been applied as a tool to measure regional oxygen saturation (rSO2), a marker of tissue oxygenation, in clinical settings including cardiovascular and brain surgery, neonatal monitoring and prehospital medicine. The NIRS monitoring devices are real-time and noninvasive, and have mainly been used for evaluating cerebral oxygenation in critically ill patients during an operation or intensive care. Thus far, the use of NIRS monitoring in patients with chronic kidney disease (CKD) including hemodialysis (HD) has been limited; therefore, we investigated rSO2 values in some organs during HD. We monitored rSO2 values using a NIRS device transmitting near-infrared light at 2 wavelengths of attachment. The HD patients were placed in a supine position, with rSO2 measurement sensors attached to the foreheads, the right hypochondrium and the lower legs to evaluate rSO2 in the brain, liver and lower leg muscles, respectively. NIRS monitoring could be a new approach to clarify changes in organ oxygenation during HD or factors affecting tissue oxygenation in CKD patients. This article describes a protocol to measure tissue oxygenation represented by rSO2 as applied in HD patients.

Cerebral rSO2 values before HD were lower than those in healthy subjects and cerebral rSO2 in HD patients with diabetes mellitus (DM) were lower than those in HD patients without DM (Figure 1)16. Furthermore, although tissue oxygenation continues without a decrease of BP during HD, we incidentally observed changes in cerebral and hepatic rSO2 due to intradialytic hypotension (Figure 2). Due to the continuo...

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Measurement of Tissue Oxygenation Using Near-Infrared Spectroscopy in Patients Undergoing Hemodialysis

We present a protocol to measure regional oxygen saturation (rSO2) in hemodialysis (HD) patients by using a near-infrared spectroscopy monitor. The rSO2 value is an index of tissue oxygenation. This noninvasive and real-time monitoring could be useful for confirming changes in organ oxygenation during HD.

Near-infrared spectroscopy (NIRS) has recently been applied as a tool to measure regional oxygen saturation (rSO2), a marker of tissue oxygenation, in ...

Using this method, we can understand oxygen dynamics of organ during hemodialysis. Prior to the development of this protocol, we could not confirm changes in regional oxygen of each organ. This simple technique can evaluate regional oxygen saturation, non-invasive and in real-time.In dialysis patients, such monitoring might detect intradyalitic hypertension or length ischemia dry during HD.This neuro system has been used in several areas. Cardiovascular and cerebrovascular surgery, neonatal, intensive care, and prehospital emergency. We hope this monitoring will be used in other areas in the future.For example, diagnosis of cognitive impairment. Begin by preparing a near-infrared spectroscopy or NIRS device for measuring tissue oxygenation. This device has four channels and can perform measurement in up to four organs at the same time.In addition, prepare measurement sensors for NIRS monitoring to evaluate regional oxygen saturation values in each organ, by a transmitting near-infrared light at two wavelengths of attachment. Allow the patient to rest in a supine position for at least five minutes before hemodialysis. Then attach measurement sensors to the forehead, the right hypochondrium and lower legs to evaluate regional oxygen saturation in the brain, liver, and lower leg muscles, respectively.For cerebral regional oxygen saturation measurement, attach the sensors to the forehead of the dominant hemisphere. For hepatic measurements, measure the depth of the patient's liver from the body surface, and confirm that this measurement is within 20 to 30 millimeters. Next, attach the measurement sensors to the right hypochondrium.To monitor muscle oxygenation, attach measurement sensors to the right or bilateral lower legs. Connect each sensor to the leads from the device. Then, turn on the device and start measuring oxygenation.Puncture the patient's dialysis shunt to start hemodialysis therapy. Measure blood pressure using a digital blood pressure monitor equipped with the dialysis machine, and collect blood samples using syringes. After starting therapy, start monitoring the tissue oxygenation of the three organs.In addition to the usual monitoring performed during hemodialysis, observe changes in regional oxygen saturation values of each organ and measure blood pressure regularly. Confirm the attachment area and connection between the sensors and leads. Cerebral oxygen saturation values of hemodialysis patients before hemodialysis were lower than those of healthy subjects.The saturation values of hemodialysis patients with diabetes mellitus were lower than those in hemodialysis patients without diabetes. Although tissue oxygenation continues without a decrease of blood pressure during hemodialysis, changes in cerebral and hepatic regional oxygen saturation due to intradyalitic hypotension were observed. When attempting this protocol, it is important to compound the location measurement sensors and to apply the sensors'registry.The new system itself is not a new technique. However, the application of this monitoring system to hemodialysis is another and it is very useful to evaluate changes in organ oxygenation during hemodialysis.

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2.0K 조회수.  Jichi Medical University. Using this method, we can understand oxygen dynamics of organ during hemodialysis. Prior to the development of this protocol, we could not confirm changes in regional oxygen of each organ. This simple technique can evaluate regional oxygen saturation, non-invasive and in real-time.In dialysis patients, such monitoring might detect intradyalitic hypertension or length ischemia dry during HD.This neuro system has been used in several areas. Cardiovascular and cerebrovascular surgery, neo...