[Automatic system control and its application in dialysis]. / I sistemi di controllo automatico e le loro applicazioni in dialisi.

ABSTRACT

The progressive increase in the mean age of dialysis patients associated with increasing comorbidity factors such as the presence of cardiovascular disease and diabetes have significantly worsened patients' clinical status and tolerance to hemodialysis. On the other hand, the demand for short treatment times increases the risk of hemodynamic instability as well as inadequate depuration. The traditional management of the dialysis session by setting predefined treatment parameters and carrying out active therapeutic intervention only in the event of complications is definitely unsuitable for short-lasting treatments, which are often complicated by hemodynamic instability, especially in critically ill patients. The first step in improving the management of the dialysis session is the use of uninvasive systems for continuous monitoring of the hemodynamic and biochemical parameters that characterize dialysis quality. In the last decade, special sensors have been designed for continuous measurement of blood volume, blood temperature, blood pressure, heart rate and electrolytes. As a second step, some of these devices have been interfaced with the dialysis equipment, mainly with a view to preventing cardiocirculatory instability but also monitoring the efficiency of dialysis (biofeedback control systems). The basic components of a biofeedback system are the plant, the sensors, the actuators, and the controller. The plant is the biological process we need to control, while the sensors are the devices used for measuring the output variables. The actuators are the working arms of the controller. The controller is the mathematical model that continuously sets the measured output variable against the reference input and modifies the actuators in order to reduce any discrepancies. In actual practice, however, there are a number of conceptual, physical and technological difficulties to overcome. In particular, the behavior of what is to be controlled may be nonlinear and time-varying, with interactions between the actuators and the controlled variable. In such cases, more sophisticated control systems are needed that must be capable of identifying the behavior of the process and continuously update information data while the control is on. These complex systems are called adaptive controllers. At present, there are three biofeedback systems routinely used in clinical dialysis. All of them are aimed at improving the cardiovascular stability during hemodialysis, which at present is one of the main problems limiting the tolerance to treatment on the one hand and the quality of hemodialysis on the other. These systems include biofeedback control of blood volume, biofeedback control of thermal balance, and biofeedback control of blood pressure.