slide1
Download
Skip this Video
Download Presentation
Yuh-Feng Lin MD

Loading in 2 Seconds...

play fullscreen
1 / 64

Yuh-Feng Lin MD - PowerPoint PPT Presentation


  • 71 Views
  • Uploaded on

Yuh-Feng Lin MD. Acute Complications of Hemodialysis. Director of Internal Medicine, Shuang-Ho Hospital,Taipei Medical University; professor, Tri-Service General Hospital. Yuh-Feng Lin M.D. ★. Intradialytic hypotension.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Yuh-Feng Lin MD' - kelly-barnett


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
acute complications of hemodialysis
Acute Complications of Hemodialysis

Director of Internal Medicine, Shuang-Ho Hospital,Taipei Medical University; professor, Tri-Service General Hospital

Yuh-Feng Lin M.D.

intradialytic hypotension

Intradialytic hypotension
  • Definition: A decrease in systolic BP ≥20 mm Hg or a decrease in MAP ≥ 10 mm Hg associated with symptoms.
  • Complication: cardiac arrhythmias, coronary and/or cerebral ischemic events
  • Long-term side effects: volume overload due to suboptimal ultrafiltration, LVH, and interdialytic hypertension

K-DOQI guildline

risk factors of dialysis hypotension
Risk Factors of Dialysis Hypotension
  • A third of dialysis patients
  • Low body mass
  • Poor nutritional status and hypoalbuminemia
  • Severe anemia
  • Advanced age (Age > 65 years old)
  • Cardiovascular disease
  • Large interdialysis weight gain
  • Low blood pressure (predialysis systolic BP <100 mm Hg)
etiology of dialysis hypotension i
Etiology of Dialysis Hypotension (I)
  • Excessive rate and degree of ultrafiltration
  • Inappropriate peripheral venodilation
  • Autonomic dysfunction
  • Inadequate vasoconstrictor secretion
etiology of dialysis hypotensoin ii
Etiology of Dialysis Hypotensoin (II)
  • Acetate dialysate
  • Low calcium dialysate
  • Eat shortly before dialysis
  • Antihypertensive medications
  • LV dysfunction
slide7

PATHOGENESIS

MEDIATORS

PATIENT

PATHOPHYSIOLOGY

Heart Disease

CARDIAC

OUTPUT

Volume

Ultrafiltration

Vascular

Disease

Osmolality

Fall

Vasopressors

Autonomic

Dysfunction

Vasodilatator

Warm

Dialysate

PERIPHERAL

RESISTANCE

Hormonal

Dysfunction

Cell

Dysfunction

Bio-incom-

patibility

Medications

Complement

Activation,

Cytokine release

Endotoxin

Sepsis

Infection

HYPOTENSiON

Acetate

Infusion

Hypoxemia

Vasovagal stim.

slide8

Table. Results of four tests of autonomic function in normotensive and hypotensive patients on maintenance hemodialysis

Before Dialysis After Dialysis

Test Normotensive Hypotensive Normotensive Hypotensive

Orthostasis (standing up)

∆SBP (mmHg) -3.7 ± 2.7 -14.1 ± 2.6* -6.0 ± 2.7 -16.0± 3.1†

∆DBP (mmHg) -4.6 ± 1.6 -11.5 ± 1.4* -4.3 ± 1.7 -10.0 ± 1.7†

30:15 ratio (normal ≥ 1.04) 1.045 ± 0.02 1.023 ± 0.014 1.036 ± 0.015 1.023 ± 0.011

Valsalva quotient (normal ≥ 1.21) 1.060 ± 0.025 1.024 ± 0.014 1.102 ± 0.028 1.012± 0.029†

Sustained handgrip (normal ≥15)

∆DBP (mmHg)5.8 ± 2.3 7.1 ± 0.7 7.2 ± 1.1 6.8 ± 0.7

Cutaneous cold

∆SBP (mmHg) 6.8 ± 1.4 7.1 ± 1.2 5.9 ± 1.0 5.6 ± 0.8

∆DBP (mmHg)5.1 ± 1.3 4.9 ± 1.4 4.5 ± 0.9 4.4 ± 0.7

Lin YF, Wang JY et al., ASAIO 39:946-953, 1993.

slide9

BV (%)

cGMP (pmol/ml)

Fig. Correlation between changes in blood volume and plasma cGMP throughout HD.

Wann GL. Lin YF. ASAIO 44:M569, 1998.

slide10

Plasma NO2- + NO3- (mM/l)

Fig. Plasma levels of nitrite and nitrate in hypotensive and normotensive patients on hemodialysis.

Lin SH. ASAIO J 42:M895, 1996.

accurate estimation of dry weight
Accurate Estimation of Dry Weight
  • cGMP, ANP
  • IVCD
  • Continuous monitoring of BV
  • Bioimpedence ECF/TBW
prevention and management of dialysis hypotension i
Prevention and Management of Dialysis Hypotension (I)
  • Limiting sodium intake
  • Minimize interdialytic weight gain by education
  • Blood sugar control
  • Slow ultrafiltration
  • Sodium modeling
  • Raise dialysate calcium
  • Lower dialysate temperature
prevention and management of dialysis hypotension ii
Prevention and Management of Dialysis Hypotension (II)
  • Switch to CAPD
  • Hyperoncotic albumin
  • Nasal oxygen
  • Mannitol infusion
prevention and management of dialysis hypotension iii
Prevention and Management of Dialysis Hypotension (III)
  • L-Carnitine therapy
  • Sertraline
  • Midodrine
  • Blood transfusion or erythropoietin therapy
  • Volume expansion
  • Vasoconstrictor
slide15

p < 0.005

Number of Hypotensive episodes

Fig. Number of hypotensive episodes per hemodialysis session in the sertraline and pre-sertraline periods.

Dheenan S. AJKD 31:624, 1998.

slide16

Figure. Serial changes in MAP HD before ( ) and after ( )midodrine therapy.

YF Lin et al. Am J Med Sci 2003;325:256-61.

conclusion and clinical application
Conclusion and clinical application
  • Midodrine improves chronic hypotensin in HD patients by modulating autonomic function and its direct effects on peripheral vessels.
slide18

Table. Carnitine levels in patients with (n=8) and without (n=23) intra-dialytic hypotension

Without hypotension With hypotension

Total carnitine (mml/l) 27.0 ± 2.7 18.4 ± 2.2*

Free carinitine (mmol/l) 18.8 ± 2.0 10.9 ± 1.7**

Acyl/free carnitine ratio 0.58 ± 0.06 0.78 ± 0.15

Values are mean ± SEM, * p < 0.05, ** p < 0.01 vs without hypotension

Riley S. Clin Nephrol 48:392, 1997.

hypoxemia
Hypoxemia
  • Alkali attenuate hyperventilation
  • Acetate dialysate
  • Complement activation
  • Pulmonary leukosequestration
  • Actin polymerization
  • Biocompatible hollow fiber
muscle cramps
Muscle Cramps
  • 35-86%of hemodialysis patients
  • Lower extremities
  • Mechanisms: Rapid ultrafiltration, Intradialytic hypotension, tissue hypoxia
  • Treatment: Quinine, Vit E, L-carnitine, Creatine monohydrate, Sodium modeling, hypertonic solution
acute allergic reaction
Acute Allergic Reaction
  • First use syndrome
  • Burning retrosternal pain
  • Diffuse heat, cold perspiration, urticaria, pruritus, laryngeal strider, bronchospasm, loss of consciousness
  • Polyurethane function as a reservoir for ethylene oxide
slide23

**

*

Serum C3a (ng/ml)

**

Fig. Comparisons of serum C3a levels during hemodialysis

procedure with different dialysis membrane.

(* p< 0.05, ** p<0.01 vs baseline)

slide24

*

*

WBC (/cumm)

**

Fig. Comparisons of WBC levels during hemodialysis

procedure with different dialysis membrane.

(* p< 0.05, ** p<0.01 vs baseline)

slide25

TNF-a (pg/ml/2 x 106 monocytes)

Fig. Comparisons of TNF-a production by zymoxan-stimulationed

Monocytes between Cuprophan and PMMA hollow fiber before, at the 15th minute of and at the end of dialysis. NC= Normal control.

** p<0.01 between two hollow fibers, +++ p<0.001 among three time periods.

YF Lin. Am J Nephorl 16:293, 1996.

slide26

Table. Clinical relevance of cytokine production in hemodialysis patients

Acute Chronic

Fever Anemia

Sleep disorders Bone disease

Hypotension Malnutrition

Immunological dysfunction

Pertosa G KI 58 suppl 76:S104, 2000.

slide27

Fig. Relationship between interleukin-6 (IL-6) production by peripheral blood mononuclear cells (PBMC) and erythropoietin (EPO) requirements in 34 hemodialysis subjects (r=0.384, p=0.039)

Goicoechea M KI 54:1337, 1998.

slide28

Serum b2 microglobulin (mg/L)

*

*

*

*

Fig. Comparisons of serum b2M during hemodialysis procedure with different dialysis membrane. (* p< 0.05 vs baseline)

uremic pruritus i

Uremic Pruritus (I)
  • 50-90%of dialysis patients
  • Risk: male, high serum BUN, Ca, P, β2-microglobulin, duration of dialysis
  • Diagnositc criteria
pathogenesis

Pathogenesis
  • Pruritogenic substancemast cell release histamine, IL-2, …cascade of nerve conduction to induce in perception of itch
uremic pruritus ii

Uremic Pruritus (II)

Topical treatment

(a) Skin emollients

(b) Capsaicin

(c) Topical steroids

Physical treatment

(a) Phototherapy

(b) Acupuncture

(c) Sauna

Systemic treatment

(a) Low-protein diet

(b) Primrose oil

(c) Lidocaine and mexilitine

(d) Opioid antagonists

(e) Activated charcoal

(f) Cholestyramine

(g) Serotonin antagonists

(h) Parathyroidectomy

(i) Nalfurafine

  • Optimize the dialysis dose
  • Treat anemia
  • Treat 2nd hyperparathyroidism
  • Ultraviolet B phototherapy
  • Topical emollients
  • Capsaicin
  • Antihistamine
  • Anti-serotonin agents
slide33

Table. Degree of pruritus on capsaicin therapy

Degree of pruritus None Mild Moderate Severe

Before treatment 0 0 8 9

After treatment * 5 9 1 2

8 weeks postreatment 4 5 5 3

arrhythmia i

Arrhythmia (I)
  • 30-48%of dialysis patients
  • Risk factor:

▲Compromised myocardium: CAD, Intermyocardiocytic fibrosis, Pericarditis

▲ Increased QT interval or dispersion

arrhythmia ii

Arrhythmia (II)

▲ Electrolyte imbalance: hypokalemia, hyperkalemia, hypercalcemia, hypermagnesemia

▲ Anemia

▲ Increased LV mass

▲ Advanced age

▲ Acetate dialysate

slide37

500

P < 0.001

450

400

350

0

Contol

(n=30)

HD

(n=42)

Fig. Distribution of QTc values among hemodialysis patients and controls.

The mean value of QTc was significantly increased in hemodialysis patients

(432.6 ± 24.9 ms) compared controls (402.0 ± 21.0 ms) (p<0.01)

Suzuki R. Clin Nephrol 49:240, 1998.

slide38

Table. Independent predictors of QTc interval by multivariate

stepwise regression analysis

Variable Coefficient Standard error T value P value

Diabetes mellitus 25.773 6.203 4.155 0.0002

Ejection fraction -111.18 42.546 -2.613 0.0127

(Constant) 494.6 28.929 17.097

Independent factor: QTc interval R2 = 0.497

Suzuki R. Clin Nephrol 49:240, 1998.

slide39

Results of 24-Hour Holter ECG Monitoring

Arrhythmias Seen No. of Tapes (%)

Ventricular ectopic beats (> 20/hr) 15 (24)

Ventricular ectopic beats (> 100/hr) 2 (3)

Episodes of ventricular tachycardia 5 (8)

Epidoses of supraventricular tachycardia 2 (3)

Episodic atrial fibrillation 7 (11)

Heart block (intermittent) 1 (1.6)

Jassal SV AJKD 30:219, 1997.

bleeding during dailysis i
Bleeding During Dailysis (I)
  • Platelet dysfunction
  • Impaired dense granule release of ATP and serotonin
  • Reduced synthesis of thromboxane A2
  • Elevated platelet cytosolic cAMP and calcium
  • Impaired aggregation response
bleeding during dialysis ii
Bleeding During Dialysis (II)
  • Altered adhesive fibrinogen and vWf
  • Impaired fibrinogen receptor (GPIIbIIIa) function
  • Uremic toxin or inhibitors
  • Erythropoietin augments GPIIbIIIa
bleeding during dialysis iii
Bleeding During Dialysis (III)
  • Pack RBC
  • Cryoprecipitate, FFP(VIII/vWF)
  • dDAVP
  • Estrogen
air embolism
Air Embolism
  • 1 ml/kg air may be fatal
  • Occlude RV outflow tract and pulmonary vascular bed
  • Thromboxane B2, endothelin
  • Trendelenburg position with left side down
  • Withdrawal of air from RA
  • Hyperbaric oxygen
dialysis pericarditis i

Dialysis Pericarditis I
  • Uremic pericarditis: pericarditis before RRT or within 8 weeks of its initiation.
  • Dialysis pericarditis: ≥ 8 weeks after initiation of RRT.
  • Incidence of dialysis pericarditis: 2-12%
  • Etiology: inadequate dialysis, volume overload, infection, autoimmune, drugs
slide45

Dialysis Pericarditis II

  • Precordial pain, hypotension, dyspnea, fever, weight gain
  • Heparin free dialysis
  • Intensive dialysis
  • NSAID
  • Subxiphoid pericardiostomy
dialysis disequilibrium i
Dialysis Disequilibrium (I)
  • Headache, vomiting, seizure, delirium
  • Rapid correction of marked azotemia
  • Cerebral swelling
  • Reverse urea effect
  • Acidosis of the CSF
dialysis disequilibrium ii
Dialysis Disequilibrium (II)
  • Inefficient dialysis
  • Shorten the duration
  • Lower dialyzer blood flow
  • Less efficient dialyzer
  • Osmotic agents, high sodium
  • IV diazepam
metabolic disorders
Metabolic Disorders
  • Metabolic alkalosis
  • Sodium citrate
  • Falty delivery of a buffer base
  • Fluoride poisoning
  • Acute cupper intoxication
sodium disorders
Sodium Disorders
  • Conductivity limits are not adjusted
  • Water intoxication
  • Hyperkalemia
  • Metabolic acidosis
  • Correction of hyponatremia
  • Drink water, 5% G/W for hypernatremia
hypokalemia
Hypokalemia
  • Loss into dialysate, alkali therapy
  • Renal or extrarenal losses
  • Arrhythmia, hypotension, fatigue, weakness, paralysis
  • CAD, digitalis, hypercalcemia, hypomagnesemia, meta alkalosis
  • Adjust dialysate potassium and buffer
hyperkalemia
Hyperkalemia
  • Dietary intake
  • GI bleeding
  • Overheated or hypotonic dialysate
  • Chloramine, sodium hypochlorite, fluoride
  • Medications
  • Metabolic acidosis
hypophosphatemia
Hypophosphatemia
  • Intensive dialysis
  • Phosphorus binders
  • Reduced intake
  • Dysfunction of erythrocytes, CNS, skeletal and cardiac muscle
  • Phosphorus rich food
hypercalcemia i
Hypercalcemia (I)
  • Liberation of calcium from bone
  • Intradialytic gain
  • Phosphorus binders
  • Widespread use of calcitriol
  • Aluminum poisoning
hypercalcemia ii
Hypercalcemia (II)
  • Low dialysate calcium
  • Phosphorus binders during meals
  • Discontinue vitamin D Therapy
  • Treat aluminum toxicity
  • Pamidronate
fluoride contamination
Fluoride Contamination
  • Faulty RO and deionization
  • Bring down calcium and magnesium
  • Vomiting, abdominal pain, cardiac irritability
  • Muscle twitching, tetany, petechiae bleeding
  • Respiratory failure, hypotension, cardiac arrest
  • Metabolic, respiratory acidosis
chloramine contamination
Chloramine Contamination
  • Less than 0.1 mg/L
  • Oxidize hemoglobin to form methemoglobin
  • Appropriate charcoal filters
  • Vitamin C
endotoxin
Endotoxin
  • Bacterial infections
  • Bicarbonate dialysate conc.
  • Endogenous pyrogens
  • Header syndrome
  • Disinfection of the O rings
  • Backfiltration with high flux dialysis
hypertensive emergencies
Hypertensive Emergencies
  • Paradoxical, hypertensive response
  • Rise in plasma catecholamine
  • Activation of renin-angiotensin system
  • Antihypertensive withdrawal
  • Sublingual captopril and nifedipine
bowel ischemia
Bowel Ischemia
  • Abdominal pain, acute diarrhea
  • Dialysis hypotension
  • Digitalis, b blockers
  • Occlusive and non-occlusive infarction (25 to 60%)
  • Congestive heart failure
  • Cardiac arrhythmia (esp. AF)
  • ESRD
  • Hyperkalemia, acidemia, leukocytosis
  • elevated LDH and CPK
slide60

Table. Location of Mesenteric Infarction

Location No. of Patients (n=12)

Small bowel 1

Colon 1

Cecum 2

Sigmoid 3

Ileocecal and distal transverse

colon 1

Diffuse involvement

Small bowel 1

Large bowel 1

Small and large bowel 1

Distal ileum and right colon 1

Diamond SM. JAMA 256:2545, 1986.

slide61

Table. Pertinent History and Medications (I)

Clinical Characteristic Bowel Infarction Controls

Heart disease

Coronary artery disease 7 8

By conornary angiography 4 3

Angina 5 4

Myocardial infarctions 2 1

Congestive heart failure 2 1

Atrial arrhythmias 3 2

Diabetics with heart disease 2 3

Diamond SM. JAMA 256:2545, 1986.

slide62

Table. Pertinent History and Medications (II)

Clinical Characteristic Bowel Infarction Controls

Cardiac medications, No. of patients 6 5

Digoxin 3 1

b-Blockers 2 1

Calcium antagonists 3 4

Episodes of hypotension when 4 3

undergoing dialysis

Frequent and/or severe hypotension 4 1

when undergoing dialysis*

Diagnosis of severe atherosclerosis 3 1

Diamond SM. JAMA 256:2545, 1986.

slide63

Table. Laboratory Values in Bowel Infarction Group

Findings No. of Patients (n=12)

White blood cell count

> 15 000 mm3 ( >15 x 109 /L) 2

> 20 000 mm3 ( > 20 x 109 /L) 6

Hematocrit

Increase by 10% (0.10) 1

Increase by 20% (0.20) 3

pH

< 7.1 4

< 7.2 1

7.2-7.35 2

7.35-7.45 2

Potassium, mEq/L (mmol/L)

> 7.0 4

> 5.0 2

Bicarbonate, mEq/L(mmol/L)

< 10 5

< 15 1

< 20 4

Diamond SM. JAMA 256:2545, 1986.

ad