1. Management of intradialytic complications
(화)

2. 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%)

3. Patterns of intradialytic BP behaviors

4. 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

5. Intradialytic hypotension: pathophysiology

6. 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

7. 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

8. 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

9. 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

10. Intradialytic hypertension : 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

11. Intradialytic hypertension : 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

12. 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, high-frequency, involuntary nerve discharge

13. Muscle cramps : etiology
Multifactorial
Plasma volume contraction
Hypotension
Changes in plasma osmolality
Hyponatremia
Tissue hypoxia
Hypomagnesemia
Carnitine deficiency
Elevated serum leptin levels

14. 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

15. 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

16. 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.

17. 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

18. Headache (Dialysis headache): 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

19. 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

20. Headache (Dialysis headache): Treatment
Amitriptyline
ACEI (Angiotensin-converting enzyme inhibitors)
Chlorpromazine
Magnesium replacement
Regular dialysis
Ergotamine
Risk of arteriovenous fistula closure

21. 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

22. Seizures : management