Transcript Management of intradialytic complications

Management of intradialytic
complications
2016.05.10 (화)
Common complications during hemodialysis
•
•
•
•
•
•
•
•
Hypertension (20-30% of dialysis)
Cramps (5-20%)
Nausea and vomiting (5-15%)
Headache (5%)
Chest pain (2-5%)
Back pain (2-5%)
Itching (5%)
Fever and chills (< 1%)
Patterns of intradialytic BP behaviors
Intradialytic hypotension (IDH)
• Definition
• Decrease in SBP by ≥ 20mmHg or decrease in MAP by 10mmHg
associated with symptoms
• Abdominal discomfort, yawning, sighing, N/V, muscle cramps,
restlessness, dizziness or fainting, anxiety
• Associated with clinical events such as cardiac arrhythmias,
vascular access thrombosis, and ischemia of cerebral, mesenteric
and coronary circulation
• Long term effects: volume overload due to suboptimal
ultrafiltration and use of fluid boluses for resuscitation; LVH; and
interdialytic hypertension
Intradialytic hypotension: pathophysiology
Intradialytic hypotension: pathophysiology
• Why do some ESRD patients not compensate appropriately to
ultrafiltration
• Results from autonomic or baroreceptor failure or disturbed
cardiac function
• Diabetes, aging, and uremia
• Cardiac disease, such as LVH, ischemic heart disease, and the
recently appreciated concept of myocardial stunning, contribute to
cardiac dysfunction with IDH
Intradialytic hypotension
• General management
• Limiting dietary sodium intake
• Especially for patients who gain excess weight in the interdialytic
period
• Increasing dry-weight
• Reduces the need to ultrafilter, but risks volume overload and
hypotension
• Fasting during dialysis
• Avoiding carbohydrate-rich food
• Adjusting antihypertensive medication or their timing
Intradialytic hypertension
• Definition
• BP increase during or immediately after HD, resulting in post-HD
BP>130/80mmHg, the KDOQI hypertension threshold
• Clinical definition
• An increase in MAP ≥ 15mmHg during or immediately after HD
• An increase SBP > 10mmHg form pre to post dialysis
• HTN during the 2nd or 3rd hour of HD after significant
ultrafiltration has taken place
• An increase in BP that is resistant to ultrafiltration
• Aggravation of pre-existing HTN or development of de novo HTN
with ESA
Intradialytic hypertension
• Prevalence
• Up to 15% of maintenance hemodialysis patients
• Clinical characteristics
•
•
•
•
More common in older patients
Patients with lower body weight
Patients with either lower serum creatinine or albumin
Be prescribed more antihypertensive medication
Intradialytic hypertension : potential mechanisms
• Potential mechanisms
•
•
•
•
•
Volume overload
Sympathetic over-activity
Activation of the renin-angiotensin-aldosterone system
Endothelial cell dysfunction
Dialysis-specific factors
• Net sodium gain: positive sodium balance, interdialytic weight gain
• High ionized calcium: increase myocardial contractility, increase
cardiac output
• Hypokalemia: direct vasoconstriction effect
• Medications
• Erythropoietin stimulating agents
• Removal of antihypertensive medications
• Vascular stiffness
Intradialytic hypertension : Management
• Management
• Related to inappropriate estimation of dry weight
• dietary salt intake restriction → reduce interdialytic weight gain
• Inhibition of the sympathetic nervous system
• Alpha- and beta- blockers such as carvedilol and labetalol
• Prevention of UF-induced RAAS activation: ACEI or ARB
• Anti-hypertensive regimen
• Time and dosing should be reviewed
• ESAs: IV ESAs can raise BP in certain individuals, consider
switching from IV to SC
• Adjustment of the dialysis prescription
• Low dialysate-serum sodium gradient
• Avoid high calcium dialysate
Muscle cramps
• A prolonged involuntary muscle contraction
• Usually associate with severe pain, both during dialysis as wall as
between dialysis session
• Common complication of HD
• Occurring in 33-86% of patients → lead to premature
discontinuation of dialysis
• Pathogenesis
• Unknown, but may be neural origin
• EMG studies
• Originate in the lower motor neurons with hyperactive, highfrequency, involuntary nerve discharge
Muscle cramps : etiology
• Multifactorial
•
•
•
•
•
•
•
•
Plasma volume contraction
Hypotension
Changes in plasma osmolality
Hyponatremia
Tissue hypoxia
Hypomagnesemia
Carnitine deficiency
Elevated serum leptin levels
Muscle cramps : Clinical features
• Involve the muscles of the lower extremity
• Occur more often in older, nondiabetic and anxious patients
• Impairing quality of life
• Serious long-term consequences: early termination of dialysis and
lead to chronic under dialysis → chronic volume overload,
hypertension and cardiac compromise
• Risk factors
•
•
•
•
Low parathyroid hormone value
High serum CPK concentration
Solute concentrations of the dialysate bath (low sodium)
Increased ultrafiltration required to remove excessive fluid
Muscle cramps : management
• Two goals
• Reducing the frequency of cramps and relieving symptoms when
they occur
• Prevention of dialysis-associated hypotension and
hypoosmolality
• Acute management: increasing the plasma osmolality
• Hypertonic saline: preferred among those with volume depletion
• 25% mannitol (50-100ml)
• 50% dextrose in water (25-50ml): may better therapeutic option
Muscle cramps : management
• Preventive management
• Non-pharmacologic therapy
• Stretching exercise, weight bearing position, etc.
• L-carnitine supplementation: energy production in tissue
dependent on fatty acid oxidation (such as skeletal muscle)
• Quinine sulfate
• Risk of drug-induced HUS, other toxic effect (cardiac arrhythmia)
• Vitamin E, vitamin C and their combination
• due to anti-oxidant effect
• Others: sequential compression device, gabapentin etc.
Headache (Dialysis headache)
• One of the most frequent neurologic symptoms reported in
HD patients is headache
• HD-related headache occurs in 27-72% of the patients
• More common in women than in men
Headache (Dialysis headache): Diagnosis
• Diagnosis
Diagnostic criteria of dialysis headache
A. At least 3 attacks of acute headache fulfilling criteria C and D
B. Patient is on hemodialysis
C. Evidence of causation demonstrated by at least two of the following
1. Each headache developing during a hemodialysis session
2. At least one of the following
a) Each headache worsening during the dialysis session
b) Each headache resolving within 72hr after the end of the dialysis
session
3. Headache episodes cease altogether after successful KT and
termination of HD
D. Not better accounted by another The International Classification of
Headache Disorders, 3rd edition diagnosis
Headache (Dialysis headache): Pathophysiology
• Closely related to depression and sleep disorders
• The anxieties of dialysis, obligation to go to a dialysis center, fear
of needle, problems in observed in other patients during dialysis
and concerns
• Caffeine-withdrawal headache
• Acceleration in caffeine elimination during HD
• Hypomagnesemia
• Cerebral vasoconstriction, increased vascular reactivity and
membrane receptor activity of several mediators such as
serotonin
Headache (Dialysis headache): Treatment
•
•
•
•
•
•
Amitriptyline
ACEI (Angiotensin-converting enzyme inhibitors)
Chlorpromazine
Magnesium replacement
Regular dialysis
Ergotamine
• Risk of arteriovenous fistula closure
Seizures
• Seizures are not uncommon in patients undergoing HD
• More frequently in those who require acute dialysis for a
severe uremic state
• Causes
•
•
•
•
•
Uremic encephalopathy
Dialysis disequilibrium syndrome (DES)
Drug: ex) erythropoietin, carbapenem, ertapenem etc.
Hemodynamic instability
Cerebrovascular disease: HTN encephalopathy, infarction,
hemorrhage
• Dialysis dementia
• Electrolyte disorders: hypercalcemia, hypocalcemia, dysnatremia
• Alcohol withdrawal
Seizures : management