Problem Based Learning Acute Complications During Hemodialysis Internal medicine, nephrology R2 이희정 Problem Based Learning

Acute Complications During Hemodialysis Cardiovascular complications Neuromuscular complications Hematologic complications Pulmonary complications Miscellaneous complications

Cardiovascular complications Intradialytic hypotension Defines as decrease in systolic blood pressure ≥20 mmHg or a decrease in mean arterial pressure by 10 mmHg ((K/DOQI) and European Best Practice Guidelines) Risk factor; Older age, longer dialysis vintage, diabetes, lower predialysis blood pressure, female gender, Hispanic ethnicity, and higher body mass index Occurs in 10-30% of treatments Ranges from asymptomatic episodes to marked organ hypoperfusion (myocardial ischemia, cardiac arrhythmia, vascular thrombosis, loss of consciousness, seizures, death)

Cardiovascular complications Intradialytic hypotension Systemic infection, arrhythmias, pericardial tamponade, myocardial infarction, hemolysis, hemorrhage, air embolism, and a reaction to the dialyzer membrane Rapid decrease of osmolarity, rapid or excessive ultrafiltration

Intradialytic hypotension-Treatment Placing in Trendelenburg position Reducing, stopping ultrafiltration Infusing bolus of 0.9% isotonic saline (100ml or more) Salt-poor albumin, or hypertonic solution offer no advantage over isotonic saline Blood flow rate should not be reduced routinely If accompanied by chest pain/dyspnea Electrocardiogram serum troponin, echocardiography Evaluated for evidence of an underlying serious cause Systemic infection, arrhythmias, pericardial tamponade, myocardial infarction, hemolysis, hemorrhage, air embolism, and a reaction to the dialyzer membrane Severity에 따라서 Fluid는 250-500ml 까지도 다른 원인감별필요 infection 등..

Intradialytic hypotension

Intradialytic hypotension-Prevention First line approach Reassess target weight Avoidance of antihypertensive drugs before dialysis Avoidance of food before/during dialysis Avoid excessive interdialytic weight gain (sodium intake)

Intradialytic hypotension★

Intradialytic hypotension-Prevention Second line approach Anemia/hypoalbuminemia correction Treatment of congestive heart failure, arrhythmias Cooling dialysate to 35.5-36℃ Increasing the time per session or by adding a fourth treatment per week Anemia 교정하여 cardiac function증가

Intradialytic hypotension Dialysate cooling Reduce the dialysate temperature to 0.5 to 1.0o C below the patient’s body temperature Total of 22 studies comprising 408 patients IDH occurred 7.1 (95% CI, 5.3–8.9) times less frequently with cool dialysis Post-dialysis mean arterial pressure was higher with cool-temperature dialysis by 11.3mmHg (95% CI, 7.7–15.0) Induce catecholamine release- results increased systemic vascular resistance and enhanced cardiac contractility

Intradialytic hypotension-Prevention Third line approach Midodrine (oral selective α1-agonist, 5-10mg) In systematic review of 10 studies, use of midodrine was associated with increase in postdialysis blood pressure Optimal dose unknown

Intradialytic hypertension Occurs in 8-30% Important risk factor for cardiovascular mortality Volume overload High cardiac output, activation of the renin-angiotensin system Increased sympathetic activity Activation of chemoreceptors within the kidney by uremic metabolites Erythropoietin (EPO) and other erythropoiesis-stimulating agents Elevation of endothelin-1 (potent vasoconstrictor) Rapid rise in hemoglobin Treatment; Volume control, prolonged frequent dialysis, hypertensive medication

Cardiovascular complications Cardiac arrhythmias Common and multifactorial in origin LVH, Congestive cardiomyopathy, uremic pericarditis, silent MI, conduction system calcification frequently encountered Polyphamacy coupled with alterations in fluid, electrolyte, acid-base homeostasis Dialysate potassium level below 2mmol/L should be avoided particularly in patients receiving digoxin d/t arrhythmogenic potential

Cardiovascular complications Sudden death 7 per 100,000 HD sessions Common in elderly, with diabetes, using central venous catheters 80% caused by ventricular fibrillation Frequent after long interdialytic interval d/t marked fluid, solute accumulation Dialysis-associated Steal syndrome More common in upper arm AV fistulas (4%) Clinical presentations ; Numbness, pain, weakness, coolness of distal arm, diminished pulses, acrocyanosis, gangrene Treatment ; Symptomatic (e.g gloves), surgical 증상에 따라 치료하는데 n m 감각 이상없고 체온만 감소되는 mild 한경우

Neuromuscular complications Muscle cramps 5-20% of patients late during dialysis, frequently involve the legs Pathogenesis unknown, dialysis-induced volume contraction, hypo-osmolality, hypomagnesemia, carnitine deficiency are common predisposing factors Acute management; increasing plasma osmolarity Infusion of 23.5% hypertonic saline(15-20ml), 25% mannitol (50-100ml), 50% dextrose in water(25-50ml) Prevention: increase dry weight by 0.5kg, quinine sulfate (250-300mg) oxazepam(5-10mg) before dialysis

Neuromuscular complications Dialysis disequilibrium syndrome Restlessness, headache, nausea, vomiting, blurred vision, muscle twitching, disorientation, tremor, hypertension, seizure, coma-usually self limited Risk factors; young age, severe uremia, rapid/marked intradialytic falls in urea at dialysis initiation, low dialysate sodium concentration Mechanism; Rapid removal of urea from blood than from cerebrospinal fluid, paradoxical cerebrospinal fluid acidosis, accumulation of intracerebral osmoles

Neuromuscular complications Seizures Occur in less than 10% of patients, and easily controlled Focal/refractory seizures-evaluation for focal neurologic disease Headache Bifrontal discomfort during dialysis, become intense, throbbing, accompanied by nausea and vomiting Aggravated by supine position, no visual disturbances Cause : DDS, caffeine withdrawl d/t removal by HD Management : Oral analgesics (e.g. acetaminophen), reduce blood flow rates, coffee ingestion during dialysis

Hematologic complications Complement activation, neutropenia During dialysis with unsubstituted cellulose dialyzer, free hydroxyl groups on membrane activates alternative pathway of complement Intradialytic hemolysis Caused by faulty dialysis equipment, chemicals, drugs, toxins, patient-related factors Hemorrhage Use of intradialytic anticoagulation Spontaneous bleeding in GI, subdural, pericardial, pleural, retroperitoneal AV malformations EPO, transfusion, IV conjugated estrogens 0.6mg/kg for 5 days, DDAVP 0.3µ/kg over15-30min, IV infusion of cryoprecipitate

Pulmonary complications Dialysis associated hypoxemia Arterial PaO2 decreased by 5-20mmHg during dialysis, resolves within 60-120min after discontinuation of dialysis Usually no clinical significance to patients unless preexisting cardiopulmonary disease Hypoventilation is the main implicated factor primarily central origin Decrease in carbon dioxide production after acetate metabolism (acetate dialysate), loss of carbon dioxide in dialyzer, rapid alkalinization of body fluids

Miscellaneous complications Pruritis Etiology is multifactorial (Xerosis, hyperparathyroidism, neuropathy, inadequate dialysis) More severe during or after dialysis, may be allergic reaction to heparin, ethylene oxide, formaldehyde, acetate, dialysis membrane Treatment ; Dialysis modification, treatment of hyperparathyroidism, topical emollients

Thank you