Patent Application
20070131595
The present invention relates to a method for conductivity calculation in a treatment fluid upstream and downstream a filtration unit in apparatuses for the blood treatment.
The invention also relates to a method for clearance and fistula flow determination using the above process for conductivity calculation.
It is known in the art to use conductivity measures for determination of parameters indicative of the filter efficiency during treatment, i.e. clearance or dialysance, and for determination of patient parameters, such as fistula flow.
EP 547025 shows a first method for determining clearance starting from a perturbation of the conductivity of the upstream dialysis liquid which creates corresponding response in the conductivity of the liquid downstream the dialysis unit.
Measures of the conductivity allow determination of downstream response and calculation of the clearance.
It is also known from EP 658352 an alternative method to calculate conductivity values for clearance calculation a short time perturbation.
It is also known to determine fistula flow by making a step like perturbation in the upstream conductivity and reversing the lines in the extracorporeal circuit during the step perturbation.
Measuring the conductivities in the spent dialysate across the flow reversal it is possible to arrive at fistula flow determination.
While the fistula flow calculation according to the above methods quite acceptable, it would be highly desirable to increase accuracy trying to reduce the time of the step like perturbation. More in general it is a goal of the invention to devise a method for conductivity determination in the spent dialysate upon a perturbation in the upstream liquid, increasing the accuracy, while keeping an acceptable measurement time.
It is also an aim of the present invention to render conductivity detections as much as possible independent from the step size, from the operating conditions and from the presence of undesired disturbances or noises.
These and other aims besides which shall be made clearer in the course of the following description, are substantially attained by a method for determining the conductivity of a treatment fluid downstream from a filtration unit in blood processing machines, as described in the accompanying claims.
Further features and advantages will become more readily apparent from the detailed description of a preferred, but not exclusive, embodiment of a process for determining the treatment fluid conductivity according to the invention.
Such description shall be made hereafter with reference to the accompanying drawings, provided purely by way of non-limiting indication:
a shows a representation of function unit_facc;
b shows the area associated to function unit_facc;
The present invention relates to a peculiar technic for determining the conductivity of a treatment fluid downstream from a filtration unit in blood processing machines and also describes one technic of how clearance and access flow can be calculated.
The method is based on studying the dialysate outlet conductivity response that follows upon rising the dialysis solution conductivity and shifting the blood flow connections to the patient.
The response of a dialysis solution conductivity step is dependent on many factors. It is therefore difficult to extract the asymptotic components needed for calculation of the clearance.
Even more so is this true for the access flow step, since the change in dialysate outlet conductivity, due to the reversal of the blood flow direction, is really small.
The algorithm described below has shown to be the one that gives the best results for both clinical data as well as data generated by a computer model.
The various variables used in the specification and in the claims later on are below defined in the table 1.
When relevant, the time interval from which data shall be extracted and processed for calculating the variable is given.
Some of the definition are also illustrated in
The following calculation method is particularly adapted for blood-treatment apparatuses having at least a filtration unit with a first compartment for the circulation of blood and a second compartment for the circulation of the treatment fluid; the first and second compartments are separated by interposition of at least a semi-permeable membrane known in the art.
The machine also comprises means for changing the conductivity of the treatment fluid upstream from the filtration unit such as a sodium reservoir and a controlled pump capable of injecting predetermined quantities of conductive fluid in the dialysate fluid up the filtration unit.
Obviously the treatment machine also comprises at least a first and a second sensor for measuring, respectively, the conductivity of the process fluid upstream and downstream from the unit.
A control unit governs said devices in order to change the conductivity of the process fluid and is able to receive the conductivity signals from the aforementioned first and second sensors allowing the calculation of the conductivity of the fluid as hereafter explained.
From a general point of view, after creating a flow of treatment fluid through the second compartment of the filtration unit, a change in the conductivity of the treatment fluid at the inlet of the filtration unit is imposed for a predetermined time interval.
The step in the Cdi curve is clearly shown in
Such a step cause thereby an induced conductivity change in the fluid at the outlet of said filtration unit (see again
After a predetermined time interval following the step in the inlet conductivity the blood flow to the fistula is reversed causing recirculation in the fistula and the consequent change in the conductivity curve downstream from the filtration unit (see the second step in the Cd0 curve—
The method allows firstly to determine the conductivity value Cdo2 of the process fluid downstream from the filtration unit after the induced conductivity change used for clearance calculation and then allows to calculate also access flow.
Clearance is calculated by studying the first part of the step response curve.
The measurement procedure is activated by the operator. Thereafter no changes to the treatment parameters are allowed in order to create stable conditions for the measurement. In a period of three minutes before the known Ultra filtration (UF) calibration, Cdo and Cdi-data are being collected. These data are necessary for the estimation of Cdo1 and Cdi1.
In connection to the UF-calibration, in fact at the end of it, a step in Cdi is initiated. After about 1 minute the response in Cdo is beginning show. After an additional of 5 minutes the operator is prompted to reverse the blood flow direction to the patient. Should the operator not have reversed the flow within 2 minutes, the measurement should be aborted.
From the time when having reversed the blood flow direction; it again takes some 1 minute until the effects show in the Cdo-curve. Just before the effects start to show we have reached as far in the measurement as to plot the curve that is seen in
Fluctuations in Cdi create fluctuations in Cdo. Since we want to study the effects in Cdo of a raise in Cdi it would have been optimal if Cdi had been constant. Of course Cdi is not constant, but one way of “making it appear constant”, is to compute the deviation that Cdi does from its mean value over the pulse, and then adjust the Cdo in proportion to it. Through this, we will expect a Cdo-curve close to the one we would have got if the response in Cdi had been equal to the actual pulse mean value.
To be able to perform this adjustment the two curves must be made synchronous. We therefore have to find the starting point of the curves and move one of them to the starting point of the other.
The synchronization process then allows to compare the conductivity curves upstream and downstream from the filtration unit after they have been synchronized in order thereby to determine one or more downstream conductivity values.
Finding the start of the Cdi pulse, is quite straightforward. It is done by assessing how the area under the step develops (should be an almost straight line), make a line fit to the pulse area “line” and see at what time it has its zero value (tACdi). Since the Cdi curve goes up quite steeply, this time point corresponds to the sought starting point of the Cdi-curve (t0Cdi).
In other words the characteristic time (t0Cdi) of the upstream conductivity curve is calculated by estimating an area defining below the inlet conductivity curve; such a characteristic time is coincident with the instant at which the area under the curve takes on an average value greater than a predetermined threshold.
The point in time of when Cdi goes back to normal, tfCdi, is also needed in the calculations later on. It could be found using the same technique as when finding t0Cdi. tfCdi is only used for referring of other time points. We can therefore equally well use the time when the machine goes back to the set value it had before the step.
The determination of the characteristic time t0Cdo of the conductivity curve downstream from the filtration unit comprises-a step consisting in a preliminary estimation of the value of the characteristic time and the preliminary estimate is subsequently corrected.
When finding t0Cdo we basically fit a curve to the initial data of the Cdo step, and where this curve intersects with Cdopre we find t0Cdo.
Prior to 3 there have been a UF calibration. As can be seen, the UF calibration will result in a “bump”. The bump might be quite big if, as in this case, there is a big difference between the patient conductivity and the set conductivity. What is shown here is quite extreme, but it shows an important case.
We know that the raise in conductivity is not made until the UF calibration is finished. This occurs when the bump is on its way downwards, i.e. at 3. Data prior to this point in time shall therefore not be used. We also know that it will take some minute before the raise in Cdi will start to show in Cdo. Therefore we can actually exclude another half a minute of data after the end of the UF calibration. We do not exclude the full 1 minute since we need to have some margin.
After any UF calibration there is always a “recoil effect”, before Cdo returns to the course it had before the UF calibration. This means that we have some data, between 3 and 1 that should not be used either. If we do, we will, in the case described by
In the case of when the patient conductivity is larger than the set conductivity, the “bump” will go downwards and the recoil effect will accordingly go upwards. This means that the condition above is not enough. In this situation, when having followed the steps above, we would get Cdo-data that has a minimum at 1 (
By excluding these data we have almost solved the problem. We are however not there yet, since we might in fact get the minimum at the “wrong end”.
We must therefore first check if there are any points lying below (or above if the step goes downwards) Cdopre. If so, we check which of them that has the latest time stamp. That one gives us the point we are looking for.
Furthermore, it can happen that all data are above Cdopre as in
The case described by
The data that now remains represents the step response and the very first data point of these data could, probably in most cases, with good enough result, be used as t0Cdo.
In other words the preliminary estimation of the value of the characteristic time of the conductivity curve downstream from the filtration unit is made by determining the average conductivity at the outlet of the filtration unit Cdopre,mean prior to the effects of the change in conductivity (the determination is made on the basis of an average, i.e. arithmetic mean, of the measured conductivity values Cdo prior to the effects of the change).
Subsequently the measured conductivity values are compared with previously determined average outlet conductivity value Cdopre,mean and then the instant which measured the conductivity values Cdo appear constantly greater than the previously calculated average outlet conductivity value Cdopre,mean is estimated.
As above stated where the measured conductivity values Cdo exceed the average outlet conductivity value Cdopre,mean a number of times, the preliminary estimate of the characteristic time t0Cdo of the conductivity curve downstream from the filtration unit, is the instant of the first condition in which the measured conductivity values Cdo are greater than the average outlet conductivity value Cdopre,mean.
We shall however undertake some “additional” steps to find an even better t0Cdo and therefore the step of correcting the preliminary estimate of the characteristic time may be performed.
We start by creating the natural logarithm function f=ln(sign*(Cdistep,set−Cdo)). The values of Cdo to use, are the ones starting at t0Cdo and extending up to the point in time when the reversion of the flow direction to the neddles is done. Cdi is the step set value, Cdistep,set, and not its actual values. The function f is scaled, by “potential”, so that it corresponds to a unit step. We call the new function unit_f (unit_f=ln(sign*(Cdistep,set−Cdo)/potential)). The reason for scaling it is of course that the calculations should be the same independently of the step size or how the patient conductivity relates to the set conductivity.
We then make a least mean square line fit to function f between t=(tRev−1.5 minutes) and t=tRev. This range represents a part of the curve where the transients have died out. The estimation is called Cdo—1nclr (Cdo—1nclr=Cdiset,step−sign*exp(cclr (1)*t+ccir (2)), cclr (1) and cclr (2) being the coefficients from the fit). We now construct a function f2clr=Cdo—1nclr−Cdo which express the short time behavior of the pulse. We standardize f2clr and get f_norm=(f2clr−min(f2clr))/max(f2clr−min(f2clr)). Again this procedure enables us to utilize the data independently of the curve form, potential and the step size. An example of the f_norm curve is shown in
The next step is to make a least mean square line fit to ln(f_norm) in the range 0.2<f_norm<0.8, i.e. the initial part of the curve (different ranges might be used e.g. 0,1:0,9). An estimation of f_norm, f_norm_est, is then given by f_norm_est=exp(cclr (3)*t+cclr (4)) where cclr (3) and cclr (4) are the coefficients generated by the line fit.
By having performed the selection of data as described above, we know that f_norm=1 corresponds to Cdo=Cdopre. This means that when f_norm_est equals the value 1 we are at what we define as t0Cdo. t0Cdo is therefore easily calculated as t0Cdo=−cclr (4)/cclr (3).
We have now got the needed t0 values and can start adjusting the data. We start by synchronizing the two curves (i.e. moving the Cdo data so that t0Cdo coincide with t0Cdi).
The mean value of Cdi during the step is calculated. To get the most appropriate mean value we use data between (t0Cdi+3 minutes) and (tfCdi−1 minute). This excludes any overshoot effects and possible end effects and focuses on data being the base for the clearance and access flow estimations. The mean value is denoted Cdistep,mean.
Also a value representing the pre step Cdo parameter is needed. We will here use a mean value of the data. It is denoted Cdopre,mean.
We are interested mainly in the big variations in Cdi and will therefore filter the signal quite hard. Only data between t=(t0Cdi+0.5 minutes) and t=(tfCdi−0.5 minutes) is filtered. The filter used is an exponential one, Cdifilt,i=(N−1)/N*Cdifilt,i−1+1/N*Cdii−1. The filter factor N used for the used data is between 150 and 250 and in detail 200. The mean sampling interval for these data is between 0.01 and 0.1 and in detail 0.033 minutes, which corresponds to a time constant of about 6.6 minutes. As start value for the filter we use Cdistep,set. The difference Cdidiff=Cdifilt−Cdistep,mean is created. A variation (ΔCdi) around the mean value is believed to give raise to a corresponding variation in Cdo (ΔCdo), see the simplified case shown in
Now that we have adjusted the data the method further comprises a step of consisting in mathematical computation of the conductivity curve downstream from the filtration unit in order thereby to determine a characteristic time tStartCF beyond which the conductivity curve has stabilized after undergoing the effects of the imposed change in conductivity. Said characteristic time tStartCF is given by the sum of two terms, a first term ttarget which is function of the conductivity curve and a second term tcbf which is function of the blood flow.
In determination of the first term ttarget for calculating the characteristic time we first estimate an intermediate time tAclr and we then derive the first term ttarget as following explained.
We will firstly obtain what we call tAclr which is a time representative of the effects of the transient due the conductivity change in the upstream liquid. Indeed tAclr depends upon several factors among which we can mention the filter volume, blood and dyalisis liquid flows, the conductivity step and so on depending on which tAclr moves near or far from the terminal instant of the transient. For obtaining tAclr we use Cdocorr data between t0Cdo and tRev. The procedure is similar to what was described for finding t0Cdi but instead of trying to find a “baseline” towards which the area under Cdocorr should be created we instead use the function unit_f above. The area referred to is therefore the one restrained by unit_f and the t-axis. We make a least mean square fit to the area data in the interval t=(tRev−1.5 minutes) and t=tRev. tAclr is then defined as the point where the line crosses the t-axis, i.e. where the line has its zero value. Since the area function is nice, i.e. very little noise, one could (to get less calculations) instead of making a least mean square fit, use a line going through the endpoints of the interval.
The next step is to construct a line going through the points (t0Cdo, Cdo0) and (tAclr, CdoA), see
To ttarget we will add a time, dependent on the blood flow (tcbf=16/60+260/Qb). The reason is that it is shown by the modeling work that the concentration in the body, Cvv (venous blood concentration), develops with a time delay of this size. This time is, since it is based on the blood flow, also linked to the shape of the Cdo curve. In the modeling work, the time used was about 1 minute. Also for clinically recorded data 1 minute was a good choice.
The time tcbf has two uses. The first is adding it to ttarget. By that, we will get to a position on the Cdo curve where most of the initial effects have decayed. The time point obtained (tstartCF) is the one from which we start using Cdo data for the subsequent estimation. The second use is for finding the best time for the clearance calculation (see below).
We choose to make the line fit to data between t=tstartCFclr and t=tstartCFclr+1.5 minutes). We assume that, by using a fixed range relative to tstartCFclr, we are using data from the same part of the curve independently of whatever parameters having influenced the curve. The line fit is the same as described above, i.e. we create the function f=ln(sign*(Cdistep,mean−Cdocorr)) and make a least mean square fit to it. Observe that the Cdi used is now the step mean value of Cdi. As before we create Cdo—1nclr=Cdistep,mean−sign*exp(c(1)*t+c(2)), where c(1) and c(2) are the coefficients from the fit. The function Cdo—1nclr will then give us the sought Cdo2 needed for the clearance calculation.
Should it not be possible to use data up to t=(tstartCFclr+1.5 minutes) for the curve fitting, i.e. tRev is passed, the rise is considered to slow and no calculation should be performed. The operator should be informed about it and what actions to take. The clearance (effective) is calculated through the expression:
where Cdi2 is equal Cdistep,mean (alternatively also the set values Cdiset,step may be used) and Cdi1 is equal to Cdipre,mean (alternatively also the set values Cdiset,pre may be used); it is also clear that, due to the symmetry of the clearance calculation expression, values of both Cdi2 and Cdi1, Cdo2 and Cdo1 may be inverted.
Cdo2 is the value that Cdo—1nclr gives at t=tCalcclr=tAclr+tcbf.
Cdo1 is given by function Cdopre, extended and taken at tCalcclr. Cdopre is created by performing a line fit to Cdo data in the same interval as is used when assessing CdOpre,mean. One may wonder why we are not creating and using an exponential function also for these data, but the reason is that it is difficult when Cdo and Cdi are close in value. Qd and Quf are the flow rates of the dialysis solution and the UF respectively.
Above is described the case where a fixed time of 1.5 minutes is used for fitting a curve to Cdo-data in order to get Cdo2. This gives, as an average, a better value on the effective clearance Ke. However, from a standard deviation of Ke point of view (if possible), it could perhaps be better to use as much data as possible from the step. If this is done we need however to move the calculation point somewhat towards the left since the whole curve and hence also Cdo2 otherwise becomes a bit too high.
As shown in
Assuming that we got the conductivity value Cdo2 from the first line fit at time t=112.1 min, to get the same Cdo2 value from the second line fit we need to move towards the left, to t=118 min.
In the real case, if, for stability reason, we would choose to use more data this would represent the second curve fit. Consequently we should move the calculation point to the left. One choice is to use t0Cdo; this is of course not the proper point but it is one that is already in the algorithm.
The access flow is calculated from the step one get when shifting the blood flow to the needles, i.e. blood taken out upstream is shifted with blood entering downstream. This creates a recirculation in the fistula, which affects the efficiency of the dialysis. Ke becomes less. How much the flow reversal reduces the efficiency is dependent on the access flow. The effect of the flow reversal is seen in the Cdo-curve as a small step (
The procedure for the access step calculations could theoretically be the same as for the clearance step. However, the noise is making this approach difficult since this step is much smaller than the clearance one. Therefore we need to do somewhat differently. We are going to describe two ways of finding the parameters needed. One that gives a more correct point for calculation of the access flow, but which might result in a larger variation. The second approach gives results which are the other way around.
The method for calculating fistula flow generally comprises the step of determining the filter clearance as above described, when reversing the blood flow direction to the fistula and determining, by means of mathematical calculation, an outlet conductivity prior the reversal of the blood flow Cdon; furthermore the method includes the step of determining a conductivity of the outlet process fluid Cdor following the reversal in blood flow and setting or estimating an inlet conductivity Cdi after the imposition of a change in conductivity.
If the switching of the blood flow to the fistula is made manually one should choose t0acc as the point-in time at which the conductivities for the access flow calculation, should be taken. When shifting manually, an overshoot in Cdo is induced. Dependent on how the shift is done (e.g. how long it takes) the overshoot will vary from time to time. t0acc is independent of how the shifting is done. Therefore, the variations in Qa become less. As in the clearance step, the correct time lies some time after t0acc.
We want our method to find consistent values of t0acc independently of if the reversion is made manually or automatically. Since the Cdo curve, in these two cases, behave differently; the method of using the area does not lead to this consistency. Therefore, the route of using the “derivative” has been chosen.
One problem of using derivatives of signals is that they usually become noisy. The first action is therefore to filter Cdocorr. The variable is called Cdo_flt. The same filter as described above is used. The difference is that the N is now 20 (with a sample time of 0.033 min this reflects a time constant of about 40 seconds).
We create the function f_fit=ln(sign*(Cdistep,mean−Cdo_flt)) and make a least mean square line fit to it between the time points t=(tfCdi−4 minutes) and t=(tfCdi−1 minute). This range represents a part of the curve where the transients have died out. The fit gives us an estimation of the of Cdo curve called Cdo—1nacc,est (Cdo—1nacc,est=Cdistep,mean−sign*exp(cacc,est(1)*t+cacc,est(2)), cacc,est (1) and cacc,est (2) being the coefficients from the fit). We now construct a function f2acc=Cdo—1nacc,est−Cdo_fit, which express the short time behavior of the pulse. Further we derive the difference function of f2acc i.e. diff_f2acc=f2acc(i)−f2acc (i−1), i being the sample number. Standardizing diff_f2acc gives us the standardized derivative of f2acc, f2der
By using the f2acc function also on its way downwards one could get a better estimate of when the transients have died out. This means that we can find a good estimate of when to start using data for the line fit of Cdocorr during the reverse flow period. The point we are going to search for is the one obtained when f2der
How the access flow is calculated is described below.
If the switching of the blood flow to the fistula is made automatically, a somewhat better point in time to use for the access flow calculation is tAacc.
tAacc is derived in the same way as was tAclr. We create the function unit_f for data between t0acc and tfCdi−1 minute (unit_facc=ln(sign*(Cdistep,mean−Cdocorr)/potential)). We derive the area function. The area referred to is the one restrained by unit_facc and the t-axis. We then make a least mean square fit to the area data in the interval t=tstartCFacc and t=tfcdi−1 minute. tAacc is then defined as the point where the line crosses the t-axis, i.e. where the line has its zero value.
In
The access flow is calculated using the expression
where Ke is the effective clearance obtained as above. Quf is the UF. The conductivities are best described by
To get the values of the conductivities we create the function f in the same way as for the clearance step. We make a least mean square line fit to the function for data lying between t=tstartCFacc and t=tfcdi−1 minute. The resulting Cdo estimation then becomes Cdo—1nacc=Cdistep,mean−sign*exp(cacc(1)*t+cacc (2)), cacc (1) and cacc (2) being the coefficients from the fit. We do the same thing for the curve prior to the reversion. For this we use data between t=tstartCFclr and t=(t0acc−0.5 minutes). As result we get Cdo—1npre,acc=Cdistep,mean−sign*exp(cpre,acc(1)*t+cpre,acc (2)).
Dependent on the situation of manual or automatic reversion of the blood flow, as described above, we use tAacc or t0acc as time point of when the conductivities are to be taken (=tCalcacc). Cdo—1npre,acc gives, at t=tCalcacc, Cdon. Cdo—1nacc gives at the same time point Cdor. Cdi is given by Cdistep,mean.
The access flow that has now been calculated is the blood water access flow Qaw. What we want is the whole blood access flow. With help from the book “Replacement of renal function by dialysis”, fourth edition, chapter 2, page 41 one can set up the following expression for the conversion:
were Hct is the hematocrit, Tp is the total plasma protein content and Fr is the red cell water fraction (volume water in red cells/total volume of red cells). If we use average values for the different quantities (Hct=35%, Tp=70 g/l and Fr=0.72) the expression becomes
Qa=1.168*Qaw
The invention achieves important advantages.
First of all it is to be noted that the method for determining the conductivity according to the present invention allows to increase the accuracy of calculation of clearance and of access flow.
The method is adapted to be used with different blood treatment machines and gives good results for different patients in different conditions.
In other words the method is general.
The present method allows also to more accurately access a conductivity needed for calculation of the clearance and of access flow by giving better estimation of the time point when the transition effect starts and ends.
Finally the conductivity detections are as much as possible independent from the step size, the operating conditions and from the presence of undesired disturbances or noises.
