Underestimation of access flow by ultrasound dilution flow measurements

For hemodialysis access surveillance, flow measurements are increasingly considered important because they identify accesses at risk of thrombosis. Usually these flow measurements are performed with the ultrasound dilution technique. In a previous patient study it was observed that the resulting flow values were systematically low as compared to magnetic resonance flow measurements, but a satisfactory explanation was lacking. In the present study, we will demonstrate by hemodynamic calculations and in vitro experiments that this discrepancy can be explained by a temporary reduction of the access flow rate, caused by the reversed needle configuration during ultrasound dilution flow measurements. In this configuration. blood is injected retrogressively at one needle and flow between the needles is increased, causing an increased dissipation of energy. The proposed explanation is subsequently confirmed in a patient with a loop graft, by measuring the blood velocity by Doppler ultrasound as a function of reversed dialyzer flow rate. Apart from the ultrasound dilution technique, these findings are applicable to other recently proposed methods for measuring access flow that employ the reversed needle configuration.