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