PANTIPA TONSAWAN, M.D. July 5, 2013 First few session care PANTIPA TONSAWAN, M.D. July 5, 2013

Scope  Relation : ESRD , HD & death  Pre HD patient evaluation  HD prescription (initial treatment)  HD complication (Initial treatment)

Impact : ESRD,HD & death

Probability of sudden cardiac death in incident dialysis patients Month after dialysis U.S. Renal Data System, USRDS 2012 Annual Data Report

Causes of death : prevalent dialysis patients, 2008–2010 ESRD pt Cardiac causes U.S. Renal Data System, USRDS 2012 Annual Data Report

Rates of sudden cardiac death : age Period prevalent dialysis patients, age 20 & older, unadjusted. U.S. Renal Data System, USRDS 2012 Annual Data Report

U.S. Renal Data System, USRDS 2012 Annual Data Report Rates of sudden cardiac death prevalent dialysis patients, by primary diagnosis Death /1000 patient years 2000 2005 2010 U.S. Renal Data System, USRDS 2012 Annual Data Report

U.S. Renal Data System, USRDS 2012 Annual Data Report Rates of sudden cardiac death following initiation of treatment in incident HD patients 0-90 days : 1/10 Death /1000 patient years 2000 2006 2007 2007 2009 U.S. Renal Data System, USRDS 2012 Annual Data Report

Caution !!! : sudden cardiac death  RRT : Hemodialysis  Aging : Exp > 65 yrs…>75 yrs  Underlying : DM, HT  Duration initial treatment : 0-90 days

Patient evaluation

Hemodialysis prescription Pre HD Evaluation Vascular access Hemodialysis prescription Patient information

Patient information 1.History taking  Indication & complication Acute or chronic HD, hyper K, volume↑  Underlying disease…DM, HT, IHD  Active problem ..GI Bleed, MI, stroke  Hemodynamic status  Arrhythmia, BP  Medication  Anti HT, anti coagulant

Patient information 2.Laboratory data  CBC :  Hb/HCT, Platelet…..risk bleeding  BUN/Cr :  High BUN…..Risk ….DDS  Electrolyte :  Select : Dialysate solution component  Serology:  HBV, HCV, HIV…..isolated

Vascular access : initial use Arteriovenous fislula Prepare : 3-6 mo ….. Maturation Prompt ? Arteriovenous graft Prepare : 3-6 wk : at least 2 wk after Surgery Infection ? HD catheter Exit site, redness, warm immediately use ..complication ?

Hemodialysis prescription

Order HD prescription (initial treatment)  Session length : Perform HD 2 hrs  BFR : 200 ml/min  Dialyzer: Low flux  Dialysate solution composition: Na …, K…., HCO3 …, Ca…, Mg…, Dextrose…..  DFR : 500 ml/min  Dialysis solution temp. : 36oc  Fluid removal order: remove … Lite Anti-coagulant : heparinloading..,maintenance … (หรือnon-heparin ตามความเหมาะสม)  50 % glucose 50-100 ml intra HD (พิจารณาตามความเหมาะสมของผู้ป่วยแต่ละราย) Daugirdas JT. Acute & Chronic hemodialysis prescription; Handbook of dialysis 2007

HD prescription (initial treatment)  Time: initial 2 hr… ↑ 30 min q HD ……until 4 hr  BFR : initial 200-250 ml/min …↑ 30 min q HD ……until 350-400 ml/min  Dialyzer : initial low flux, low SA …. (AIM ….Kt/V 0.6-0.7, URR 40 %)  DFR : 500 ml/min …800ml/min (high BFR) Daugirdas JT. Acute & Chronic hemodialysis prescription; Handbook of dialysis 2007

HD prescription (initial treatment)  Dialysate composition : Na K Ca HCO3 Acute 145 2, 3, 4 3.5 25 Chronic 135-145 2,3 2.5 32  Temp. : low temp prevent Hypotension 36.5 C  UF : < 1 L /hr, ….if need…sequential HD  Hypertonic solution : 50 % glucose ….DDS  Anticoagulant : depend on patient. condition Daugirdas JT. Acute & Chronic hemodialysis prescription; Handbook of dialysis 2007

Hemodialysis complications

Dialysis disequilibrium syndrome Acute neurological complication Consequence of rapid HD …osmotic gradient brain Vs plasma caused .. cerebral edema Risk factor 1st session hemodialysis  Extreme age : child or aging  High BUN level: > 125 mg/dl  CNS disorder (stroke, tumor, dementia,hypo Na), head injury (subdural hematoma) …. Pediatr Nephrol (2012) 27:2205–2211 Seminars in Dialysis—Vol 20, No 3 2008 pp. 493–498

Dialysis disequilibrium syndrome ICF ECF IVF I Urea CF : brain ICF : brain Brain Urea Urea H2O Urea↑ High Osm Urea H20 slow Reverse osmotic shift HD Cerebral edema

Dialysis disequilibrium syndrome Clinical : fatigue, mild headache, nausea, vomiting, disturbed consciousness, convulsions… coma. Common mild..Self limited, fatal.. if severe Diagnosis Clinical diagnosis (during HD, after HD) + risk factor Exclusion other condition Treatment Symptomatic treatment/ hypertonic solution/ + stop HD Seminars in Dialysis—Vol 20, No 3 2008 pp. 493–498

Dialysis disequilibrium syndrome Prevention Most important  Dialysis time (2 hours) Blood flow rate 200 ml/min  Less efficient (small) dialyzer  Hypertonic solution  A goal URR : 0.4–0.45 or diffusive Kt/V of 0.6–0.7 Seminars in Dialysis—Vol 20, No 3 2008 pp. 493–498

Cardiac arrhythmia, Ischemia, sudden death  DIALYSIS-INDUCED MYOCARDIAL STUNNING Echocardiogram - Pre HD …normal - During HD …. RWMA abnormality - Post HD 30 min …normal Semin Dial 2007; 20: 220–228  Positron emission tomography : Measure ..MBF dialysis ….. HD precipitates reductions MBF CAG …..normal Clin J Am Soc Nephrol 2008; 3: 19–26. Effects of hemodialysis on cardiac function ;Kidney International (2009) 76, 371–375

Cardiac arrhythmia, Ischemia, sudden death  DIALYSIS-INDUCED CARDIAC ISCHEMIA Myocardial stunning : Occur ….60 % Related to UF (total/rate ) & HD instability Long term High mortality PET Effects of hemodialysis on cardiac function ;Kidney International (2009) 76, 371–375

Intradialytic hypotension Initial treatment : associated cause High UF rate : limit time Trial & error : set DW High dose : anti HT Nutrition status : malnutrition …low plasma refilling Treatment  Sequential HD  Limit IDWG < 1 kg/day  Decrease anti HT ….decrease DW  Avoid : eating during HD  low Temp.

Type A : anaphylactic type Dialyzer reaction Type A : anaphylactic type Type B :non-specific  Full brown, Severe reaction  Common : 5 min after HD…but delayed 30 min  Cause : ETO oxide, AN 69 reaction, contaminated dialysis solution, reuse First use syndrome Management : Safest to stop dailysis, without returning blood  Cardiorespiratory support Prevention : proper rinsing, y-irradiated or stream-sterilized dialyzer

Dialyzer reaction  Supportive care Type B :non-specific  Mild symptoms : chest pain, back pain  Onset 20-30 min after HD  Cause : unknown Management :  Supportive care  Differential diagnosis : coronary artery disease

Post HD care Complication Next session HD

Summary  Cardiovascular : common cause of death HD patient  Risk : aging, DM, HT, HD 0-90 day  Pre HD patient evaluation: important …Recognized risk of HD complication  Appropriate HD prescription …reduce & prevent HD complication  Prompt to treatment of complication : if HD… started