PANTIPA TONSAWAN, M.D.July 5, 2013

First few session care

Scope Relation : ESRD , HD & death

Pre HD patient evaluation

HD prescription (initial treatment)

HD complication (Initial treatment)

Impact : ESRD,HD & death

USRDS 2012 ADR

Probability of sudden cardiac death in incident dialysis patients

U.S. Renal Data System, USRDS 2012 Annual Data Report

Prob

abili

ty

Month after dialysis

USRDS 2012 ADR

Causes of death : prevalent dialysis patients, 2008–2010

Cardiac causes

U.S. Renal Data System, USRDS 2012 Annual Data Report

ESRD pt

USRDS 2012 ADR

Rates of sudden cardiac death : age

Period prevalent dialysis patients, age 20 & older, unadjusted.

U.S. Renal Data System, USRDS 2012 Annual Data Report

USRDS 2012 ADR

Rates of sudden cardiac death prevalent dialysis patients, by primary diagnosis

U.S. Renal Data System, USRDS 2012 Annual Data Report

2000 2005 2010

Deat

h /1

000

patie

nt y

ears

USRDS 2012 ADR

Rates of sudden cardiac death following initiation of treatment in incident HD patients

0-90 days : 1/10

U.S. Renal Data System, USRDS 2012 Annual Data Report

2000 2006 2007 2007 2009

Deat

h /1

000

patie

nt y

ears

Caution !!! : sudden cardiac death

RRT : Hemodialysis Aging : Exp > 65 yrs…>75 yrs Underlying : DM, HT Duration initial treatment :

0-90 days

Patient evaluation

Pre HD Evaluation

Patient information

Vascular access

Hemodialysis prescription

Patient information1.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 information2.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 useArteriovenous fislula

Arteriovenous graft

HD catheter

Prepare : 3-6 mo….. Maturation

Prepare : 3-6 wk : at least 2 wk after Surgery

immediately use ..complication ?

Prompt ?

Infection ?

Exit site, redness, warm

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 … LiteAnti-coagulant : heparinloading..,maintenance …

(หรอnon-heparin ตามความเหมาะสม) 50 % glucose 50-100 ml intra HD

(พจารณาตามความเหมาะสมของผปวยแตละราย)Daugirdas JT. Acute & Chronic hemodialysis prescription; Handbook of dialysis 2007

HD prescription (initial treatment)

Daugirdas JT. Acute & Chronic hemodialysis prescription; Handbook of dialysis 2007

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)

HD prescription (initial treatment)

Daugirdas JT. Acute & Chronic hemodialysis prescription; Handbook of dialysis 2007

Dialysate composition :

Temp. : low temp prevent Hypotension 36.5 C

UF : < 1 L /hr, ….if need…sequential HD

Na K Ca HCO3Acute 145 2, 3, 4 3.5 25Chronic 135-145 2,3 2.5 32

Hypertonic solution : 50 % glucose ….DDS

Anticoagulant : depend on patient. condition

Hemodialysis complications

Dialysis disequilibrium syndrome Acute neurological complicationConsequence 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) ….

Seminars in Dialysis—Vol 20, No 3 2008 pp. 493–498

Pediatr Nephrol (2012) 27:2205–2211

Dialysis disequilibrium syndrome

IUrea CF :

brain

ICF ICF

: brai

n

IVF ECF

Brain

UreaH20

H2OUrea↑High Osm

HD

Urea

Cerebral edema

Reverse osmotic shift

Urea

slow

Dialysis disequilibrium syndrome

Diagnosis

Treatment

Clinical : fatigue, mild headache, nausea, vomiting, disturbed consciousness, convulsions… coma.

Common mild..Self limited, fatal.. if severe

Clinical diagnosis (during HD, after HD)+ risk factor Exclusion other condition

Symptomatic treatment/ hypertonic solution/ + stop HD

Seminars in Dialysis—Vol 20, No 3 2008 pp. 493–498

Prevention

Dialysis disequilibrium syndrome Most important

Dialysis time (2 hours)

Blood flow rate 200 ml/min

Less efficient (small) dialyzer

A goal URR : 0.4–0.45 or diffusive Kt/V of 0.6–0.7

Hypertonic solution

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

Positron emission tomography : Measure ..MBF dialysis ….. HD precipitates reductions MBF

CAG …..normal

Effects of hemodialysis on cardiac function ;Kidney International (2009) 76, 371–375

Clin J Am Soc Nephrol 2008; 3: 19–26.

Semin Dial 2007; 20: 220–228

Cardiac arrhythmia, Ischemia, sudden death

DIALYSIS-INDUCED CARDIAC ISCHEMIA

Myocardial stunning : Occur ….60 %Related to UF (total/rate ) & HD instability

Effects of hemodialysis on cardiac function ;Kidney International (2009) 76, 371–375

High mortalityPET

Long term

Intradialytic hypotension

Initial treatment : associated cause

High UF rate : limit time Trial & error : set DWHigh dose : anti HTNutrition status : malnutrition …low plasma refilling

Treatment Sequential HD Limit IDWG < 1 kg/day Decrease anti HT ….decrease DW Avoid : eating during HD low Temp.

Dialyzer reaction

Full brown, Severe reaction Common : 5 min after HD…but delayed 30 min Cause : ETO oxide, AN 69 reaction, contaminated

dialysis solution, reuse

Type A : anaphylactic type

Management : Safest to stop dailysis, without returning blood Cardiorespiratory support

Prevention : proper rinsing, y-irradiated or stream-sterilized dialyzer

First use syndrome

Type B :non-specific

Dialyzer reaction

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

USRDS 2012 ADR

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