Chronic hemodialysisChronic hemodialysisChronic hemodialysisChronic hemodialysis

Acute HemodialysisAcute HemodialysisAcute HemodialysisAcute Hemodialysis

Treatment of poisoningTreatment of poisoningTreatment of poisoningTreatment of poisoning

ConvectionNa

KPo4

BUN

Cr

DialysisNa

yK

BUN

Po4

Cr

Complications of Central Vein pCanulation

InsertionInsertionInsertion Insertion ComplicationsComplicationsComplicationsComplicationsInfectionInfectionCatheter ThrombosisCatheter ThrombosisCentral Vein StenosisCentral Vein Stenosis

Remove catheter ifRemove catheter if::F /F / i if b i i ii if b i i iFever +/Fever +/-- rigor, if no obvious origin rigor, if no obvious origin for infectionfor infectionExit site drainage (+/Exit site drainage (+/-- systemic systemic

i )i )signs)signs)>> 7272 hours in the femoral cathetershours in the femoral catheters> > 72 72 hours in the femoral catheters hours in the femoral catheters (except in ICU patients) (except in ICU patients) Insert ional complications (arterial Insert ional complications (arterial puncture,…)puncture,…)puncture,…)puncture,…)Thrombosis and malfunctionsThrombosis and malfunctions

Vascular Access Complications:Vascular Access Complications:Vascular Access Complications:Vascular Access Complications:

Most commonMost commonMost commonMost common P blP blMost commonMost commonMost commonMost common Problems Problems Most harmfulMost harmfulMost harmfulMost harmful In In

DialysisDialysisMost cost burdenMost cost burdenMost cost burdenMost cost burden

yPatients

yPatients

Hand Ischemia Hand Ischemia (Steal (Steal Hand Ischemia Hand Ischemia (Steal (Steal Phenomena): Phenomena): Phenomena): Phenomena):

Arterial insufficiencyArterial insufficiencyArterial insufficiencyArterial insufficiency

Venous hypertensionVenous hypertensionVenous hypertensionVenous hypertension

Hand Ischemia (Steal Hand Ischemia (Steal Phenomena):Phenomena): Arterial insufficiency:Arterial insufficiency:Phenomena):Phenomena): Arterial insufficiency:Arterial insufficiency:Is more common in grafting of large Is more common in grafting of large

l d l ti (DM SLE)l d l ti (DM SLE)vessels and vasculopaties (DM, SLE)vessels and vasculopaties (DM, SLE)

Allen testAllen test

Hand Hand Ischemia Ischemia (Steal (Steal Phenomena)Phenomena)Phenomena):Phenomena):Venous Venous h t ih t ihypertensionhypertension(Sore(Sore--Thumb Thumb S )S )Sy)Sy)

Predisposing factors to Predisposing factors to aneurysm &pseudoaneurysm:aneurysm &pseudoaneurysm:

Repeated puncture siteRepeated puncture siteInfectionInfectionS b t bl diS b t bl diSubcutaneous bleedingSubcutaneous bleedingStenosis in proximal veinStenosis in proximal veinStenosis in proximal veinStenosis in proximal vein

Insufficient Blood Flow From AInsufficient Blood Flow From A--V Fistula During DialysisV Fistula During Dialysis

Hypotension, Muscle cramp, Low Sodium

Complications related to Dialysate (1)

ON yp , p,

Hemolysis, Dysequilibrium SY

Thirst,Interdialysis weight gainHigh Sodium

OSI

TIO

Cardiac Arrhythmia, Hypertension Low Potassium

OM

PO

Cardiac Arrhythmia High Potassium

Mild Hypotension, HPT, Twitching, Low CalciumTE C

O

Mild Hypotension, HPT, Twitching, tetany, Petechia

Low Calcium

Hypertension, Arrhythmia, tissue High CalciumOLY

T

calcification, hard water Sy

HPT Low magnesiumEC

TRO

magnesiumOsteoprosis and osteomalacia,Nausea, Blurred vision, weakness, hypotension

High MagnesiumEL

E

Complications related to Dialysate (2)E T

COSE

NT

ENT

HypoglycemiaNo

GLU

CCO

N Hypoglycemia( Rare)

No glucose

Hypotension, Arrhythmia, Headache, Hypoventilation,

H i H i

Acetate

uffe

r Hypocapnia, Hypoxia

Bu Metabolic Alkalosis, Bacterial overgrowthBicarbonate

Complications related to Dialysate (3)

LOWE

Hypothermia, Chills

LOWAT

URE Chills

PERA

T

S ti WHIGH

TEM

PE Sweating, Warmness, Hypotension,

Hyperventilation

HIGH

TE Hyperventilation, Tachycardia,Vomitting,

Hemolysis and yHyperkalemia

Complications related to Dialysate (4)

NHemolysis and hyperkalemia, Hyrogen Peroxide,

ATIO

Ny yp ,

Methemoglobinemia resulting cyanosis, Bownish

discoloration of venous blood

y g ,Formaldehyde, Hypochlorite,

Chloramine Nitrate

TAM

INA discoloration of venous blood,

fatigue, malaise, Coma Chloramine, Nitrate,

Copper

CONT

A

EARLY: nausea, vomitting, pruritis headache Syncope

Floride

SATE

C pruritis, headache, Syncope, bach and abdominal pain,

diarrhea, arrhythmia

DIAL

YS

LATER: Symptoms related to precipitation of calciumD precipitation of calcium,

respiratory failure, hypotension, seizure, coma

Complications related to Dialysate (5)

NAT

ION

Fever, Hypotension, Shock Malnutrition

TAM

INA Shock, Malnutrition,

Arthropathies, Amyloidosis Liver

CONT

A Amyloidosis, Liver failure (microcystins

fromMicroorganisms and Pyrogens

SATE

C from Cyanobacteria)

and Pyrogens

DIAL

YSD

Factors Resulting in a Reduction of the prescribed Dose of Hemodialysis Delivered (1)y ( )

1) Compromised urea clearance– Access recirculation

I d t bl d fl f th l– Inadequate blood flow from the vascular access– Inaccurate estimation of dialyzer performance– Inadequate dialyzer perocessing related to inadequateInadequate dialyzer perocessing related to inadequate

quality control of reuse– Blood pump/ dialysate flow calibration errors

Di l l tti d i di l i ( hi h d– Dialyzer clotting during dialysis ( which reduces effective dialyzer surface area )

– Errors in prescribed blood and dialysate flow rate due to p yvariablility in blood pump tubing

– Dialysate flow that is inappropriately set too low– Dialysate flow miscalibration– Dialysate flow miscalibration– Dialyzer reuse

Factors Resulting in a Reduction of the prescribed Dose of Hemodialysis Delivered (2)

2) Reductions in treatment time

y ( )

)– Inaccurate assessment of effective time (e.g. Use of clock)– Incorrect assumption of continuous treatment time

di i i f h di l i h i– Premature discontinuation of hemodialysis to honor patientrequest / adherence

– Premature discontinuation of hemodialysis for staff or unitPremature discontinuation of hemodialysis for staff or unit convenience, e.g. ,due to scheduling conflicts

– Delayed in starting dialysis session due to patient tardinessi k ff di l i– Wrong patient taken off dialysis

– Time on dialysis calculated incorrectlyTime read incorrectly for initiation or completion of– Time read incorrectly for initiation or completion of hemodialysis

Factors Resulting in a Reduction of the prescribed Dose of Hemodialysis Delivered (3)

3) Laboratory or blood sampling errors

y ( )

) y p g– Dilution of predialysis BUN blood sample with saline– Drawing predialysis BUN blood sample after the start ofDrawing predialysis BUN blood sample after the start of

dialysis– Laboratory error due to calibration or equipment problemsy q p p– Drawing post dialysis BUN blood sample before the end of

dialysisy– Drawing post dialysis BUN blood sample before 5 minutes

after dialysis– Laboratory error in the BUN measurement

C li ti D i HD Complications During HD hypotension (20%-30% of dialyses),cramps (5%-20%),p ( )nausea and vomiting (5%-15%), headache (5%),( %),chest pain (2%-5%),back pain (2%-5%)back pain (2% 5%),itching (5%),and fever and chills (<1%)and fever and chills (<1%).

Is the most frequent problem in chronic HDHypotension During HD

Is the most frequent problem in chronic HD patients ( it occurs in 20-50% of patients).Incidence of hypotension during HD has not been declined in the recent past 20pyears. Because acceptance of more older and more severe ill patients in HD andand more severe ill patients in HD and shorter times HD .I t di l i h t i t ib t tIntra-dialysis hypotension contributes to overall patients morbidity, limits fluid removal during dialysis and increases the need for nursing interventions.

R id fl id l ( h i l bili )

Etiology Of Hypotension During HD (1)Rapid fluid removal (more than patient tolerability).Underestimation of dry weight.Rapid reduction of plasma osmolality.Autonomic neuropathy.Diminished cardiac reserve.Use of acetate rather than bicarbonate as the dialyset buffer.Intake of antihypertensive drugs prior of dialysis.Use of low sodium concentration in dialyset.

Etiology Of Hypotension During HD (2)

Ingestion of meals during or just before di l idialysis.

Arrhythmia or severe pericardial effusion.Arrhythmia or severe pericardial effusion.

Inflammatory reaction to dialysis membrane.

Release of NO during HD.

Rare causes such as sepsis, air embolism, hemolysis, bleedinghemolysis, bleeding.

Release of adenosine.

Ischemia ATP breakdown

Decreased CO

Adenosine release

Vasodilatation

Prevention 0f Hypotension During HD (1)

Exclude cardiac causes and treat it.Avoid eating during HD.g gWithhold antihypertensive agents on the day of HDof HD.Reassess of dry weight.Correction of anemia with Erythropoietin. Intra-dialysis Dubotamine infusion.Intra dialysis Dubotamine infusion.Pre dialysis Midodrine (an alpha 1 agonist) or Sertraline (Serotonin reuptake blocker)or Sertraline (Serotonin reuptake blocker).

Prevention Of Hypotension During HD (2)

Cool temperature dialysis.Change of acetate dialysis to bicarbonateChange of acetate dialysis to bicarbonate dialysis.Adj t di l t di d ++Adjust dialyset sodium and ca++.Sodium modeling ( sodium ramping).g ( p g)Sequential UF.C t t UF # UF d liConstant UF # UF modeling.Caffeine as an adenosine receptor pblocker.

Muscle cramp During HD

waterwater

pre exercise post exercise

8090

10096.3UTi

50607080

84.4P<0.0005P<0.0005

10203040

44.949.6

42.3

45.8

8.4 8.93 2 1 6.9 8.2

P<0.05 P<0.0005P<0.005

010

symp

affec

well b

functi

objec

Subje

3 2.1

mptoms scoreect score

ll being

ctional disabiljective qualitybjective qualit

Changes in quality of life pre and post exercise during dialysis e bility

ty ity

1.13 1.1** ** * *

0.810.92

1.01

1

1.2

0 6

0.8

0.4

0.6

0

0.2

pre exercise

1 month lat

2 months la

3 months la

4 months la*p<0 05

KT/V increased after exercise during dialysisse ater

later

later

later*p<0.05**p<0.005

2 22.33 2.38 2.46*

**

1.85

2.2

2

2.5

1.5

2

0 5

1

0

0.5

/k /d pre exercise

1 month lat

2 months la

3 months la

4 months la*p<0 025

gr/kg/day

nPCR is increased after exercise during dialysisse ater

later

later

later*p<0.025**p<0.01

Hypertension during HD

Consequences of hypertension in DialysisConsequences of hypertension in DialysisCardiovascular DiseasesCardiovascular Diseases

LVH& CHF& IHD LVH& CHF& IHD M li & NM li & N li li Malignant& NonMalignant& Non--malignant malignant hypertension hypertension SS k (i h i h h i ) k (i h i h h i ) SStroke (ischaemic, haemorrhagic) troke (ischaemic, haemorrhagic) Vessel wall remodellingVessel wall remodelling(h h /h l i f i i & (h h /h l i f i i & (hypertrophy/hyperplasia of intima& (hypertrophy/hyperplasia of intima& media)media)Al d li f l i iAl d li f l i iAltered compliance of elastic arteriesAltered compliance of elastic arteriesEndothelial cell dysfunction?Endothelial cell dysfunction?

Causes of poor BP control in HD patients

Physician errorsP ti t liPatients non complianceInadequate UFqInadequate dialysisI d t tih t i dInadequate antihypertensive drugUnderlying secondary hypertensiony g y ypLack of a clear guideline for therapy

Am J Kidney Dis. [suppl 3], s120-s141; 1998

Mechanisms of Hypertension in CRF:

Expansion of ECF volume RAA system stimulationyIncreased sympathetic activityEndogenous digitalis-like factorg gProstaglandin/BradykininsAlteration of NO/endothelin/Increased body weightIncreased PTH and intracellular CaCalcification of arterial treePreexisting essential hypertensiong ypRVD and RAS

Hypertension during dialysis:Hypertension during dialysis:

Intermittent hypertension ypin the last hours of dialysisy

Treatment: Treatment:

Sub Lingual Therapy of Hypertensive Emergencies during dialysis:Emergencies during dialysis:

90%83%90%

ff ti83%

70%

80%effctiveness

complications

50%

60%

30%

40%

0%

14% 11%

0%10%

20%

0% 0%0%

Captopril Nifedipine PrazocinNephron; Nephron; 6565: : 284284--287287, , 19931993

Dialysis Disequilibrium Syndrome:Dialysis Disequilibrium Syndrome:

nausea and vomiting, restlessness, headaches, and fatigue during HD or in the immediate postdialysis period

Decreased urea concentration very fast

Arrhythmia and Angina during HD Arrhythmia and Angina during HD

Special attention to hypokalemia and digoxin

Hypoglycemia during hemodialysis Hypoglycemia during hemodialysis

Insulin dose should be reduced in the dialysis days

Hemorrhage during hemodialysis Hemorrhage during hemodialysis

Blood membrane interactionsBlood membrane interactions

Complications of CRRT (1)

:Technical Complications

1) Vascular access malfunction

2) Bl d fl d ti & l tti2) Blood flow reduction & clotting

3) Line disconnection3) Line disconnection

4) Air embolism

5) Fluid& Electrolyte disorders

6) Loss off filter efficacy

Complications of CRRT (2)

Cli i l C li ti :Clinical Complications1) Bleeding1) Bleeding

2) Thrombosis

3) Infection& Sepsis

4) Biocompatibility& Allergic reactions

5) Hypothermia5) Hypothermia

6) Nutrient loss6) ut e t oss

7) Inadequate blood purification