1. Problem Based Learning
Acute Complications During Hemodialysis
Internal medicine, nephrology
R2 이희정
Problem Based Learning

2. Acute Complications During Hemodialysis
Cardiovascular complications
Neuromuscular complications
Hematologic complications
Pulmonary complications
Miscellaneous complications

3. Cardiovascular complications
Intradialytic hypotension
Defines as decrease in systolic blood pressure ≥20 mmHg or a decrease in mean arterial pressure by 10 mmHg
((K/DOQI) and European Best Practice Guidelines)
Risk factor;
Older age, longer dialysis vintage, diabetes, lower predialysis blood pressure, female gender, Hispanic ethnicity, and higher body mass index
Occurs in 10-30% of treatments
Ranges from asymptomatic episodes to marked organ hypoperfusion (myocardial ischemia, cardiac arrhythmia, vascular thrombosis, loss of consciousness, seizures, death)

4. Cardiovascular complications
Intradialytic hypotension
Systemic infection, arrhythmias, pericardial tamponade, myocardial infarction, hemolysis, hemorrhage, air embolism, and a reaction to the dialyzer membrane
Rapid decrease of osmolarity, rapid or excessive ultrafiltration

5. Intradialytic hypotension-Treatment
Placing in Trendelenburg position
Reducing, stopping ultrafiltration
Infusing bolus of 0.9% isotonic saline (100ml or more)
Salt-poor albumin, or hypertonic solution offer no advantage over isotonic saline
Blood flow rate should not be reduced routinely
If accompanied by chest pain/dyspnea
Electrocardiogram serum troponin, echocardiography
Evaluated for evidence of an underlying serious cause
Systemic infection, arrhythmias, pericardial tamponade, myocardial infarction, hemolysis, hemorrhage, air embolism, and a reaction to the dialyzer membrane
Severity에 따라서
Fluid는 ml 까지도
다른 원인감별필요 infection 등..

6. Intradialytic hypotension

7. Intradialytic hypotension-Prevention
First line approach
Reassess target weight
Avoidance of antihypertensive drugs before dialysis
Avoidance of food before/during dialysis
Avoid excessive interdialytic weight gain (sodium intake)

8. Intradialytic hypotension★

9. Intradialytic hypotension-Prevention
Second line approach
Anemia/hypoalbuminemia correction
Treatment of congestive heart failure, arrhythmias
Cooling dialysate to ℃
Increasing the time per session or by adding a fourth treatment per week
Anemia 교정하여 cardiac function증가

10. Intradialytic hypotension
Dialysate cooling
Reduce the dialysate temperature to 0.5 to 1.0o C below the patient’s body temperature
Total of 22 studies comprising 408 patients
IDH occurred 7.1 (95% CI, 5.3–8.9) times less frequently with cool dialysis
Post-dialysis mean arterial pressure was higher with cool-temperature dialysis by 11.3mmHg (95% CI, 7.7–15.0)
Induce catecholamine release- results increased systemic vascular resistance and enhanced cardiac contractility

11. Intradialytic hypotension-Prevention
Third line approach
Midodrine (oral selective α1-agonist, 5-10mg)
In systematic review of 10 studies, use of midodrine was associated with increase in postdialysis blood pressure
Optimal dose unknown

12. Intradialytic hypertension
Occurs in 8-30%
Important risk factor for cardiovascular mortality
Volume overload
High cardiac output, activation of the renin-angiotensin system
Increased sympathetic activity
Activation of chemoreceptors within the kidney by uremic metabolites
Erythropoietin (EPO) and other erythropoiesis-stimulating agents
Elevation of endothelin-1 (potent vasoconstrictor)
Rapid rise in hemoglobin
Treatment; Volume control, prolonged frequent dialysis, hypertensive medication

13. Cardiovascular complications
Cardiac arrhythmias
Common and multifactorial in origin
LVH, Congestive cardiomyopathy, uremic pericarditis, silent MI, conduction system calcification frequently encountered
Polyphamacy coupled with alterations in fluid, electrolyte, acid-base homeostasis
Dialysate potassium level below 2mmol/L should be avoided particularly in patients receiving digoxin d/t arrhythmogenic potential

14. Cardiovascular complications
Sudden death
7 per 100,000 HD sessions
Common in elderly, with diabetes, using central venous catheters
80% caused by ventricular fibrillation
Frequent after long interdialytic interval d/t marked fluid, solute accumulation
Dialysis-associated Steal syndrome
More common in upper arm AV fistulas (4%)
Clinical presentations ; Numbness, pain, weakness, coolness of distal arm, diminished pulses, acrocyanosis, gangrene
Treatment ; Symptomatic (e.g gloves), surgical
증상에 따라 치료하는데 n m 감각 이상없고 체온만 감소되는 mild 한경우

15. Neuromuscular complications
Muscle cramps
5-20% of patients late during dialysis, frequently involve the legs
Pathogenesis unknown, dialysis-induced volume contraction, hypo-osmolality, hypomagnesemia, carnitine deficiency are common predisposing factors
Acute management; increasing plasma osmolarity
Infusion of 23.5% hypertonic saline(15-20ml), 25% mannitol (50-100ml), 50% dextrose in water(25-50ml)
Prevention: increase dry weight by 0.5kg, quinine sulfate ( mg) oxazepam(5-10mg) before dialysis

16. Neuromuscular complications
Dialysis disequilibrium syndrome
Restlessness, headache, nausea, vomiting, blurred vision, muscle twitching, disorientation, tremor, hypertension, seizure, coma-usually self limited
Risk factors; young age, severe uremia, rapid/marked intradialytic falls in urea at dialysis initiation, low dialysate sodium concentration
Mechanism; Rapid removal of urea from blood than from cerebrospinal fluid, paradoxical cerebrospinal fluid acidosis, accumulation of intracerebral osmoles

17. Neuromuscular complications
Seizures
Occur in less than 10% of patients, and easily controlled
Focal/refractory seizures-evaluation for focal neurologic disease
Headache
Bifrontal discomfort during dialysis, become intense, throbbing, accompanied by nausea and vomiting
Aggravated by supine position, no visual disturbances
Cause : DDS, caffeine withdrawl d/t removal by HD
Management : Oral analgesics (e.g. acetaminophen), reduce blood flow rates, coffee ingestion during dialysis

18. Hematologic complications
Complement activation, neutropenia
During dialysis with unsubstituted cellulose dialyzer, free hydroxyl groups on membrane activates alternative pathway of complement
Intradialytic hemolysis
Caused by faulty dialysis equipment, chemicals, drugs, toxins, patient-related factors
Hemorrhage
Use of intradialytic anticoagulation
Spontaneous bleeding in GI, subdural, pericardial, pleural, retroperitoneal AV malformations
EPO, transfusion, IV conjugated estrogens 0.6mg/kg for 5 days, DDAVP 0.3µ/kg over15-30min, IV infusion of cryoprecipitate

19. Pulmonary complications
Dialysis associated hypoxemia
Arterial PaO2 decreased by 5-20mmHg during dialysis, resolves within min after discontinuation of dialysis
Usually no clinical significance to patients unless preexisting cardiopulmonary disease
Hypoventilation is the main implicated factor primarily central origin
Decrease in carbon dioxide production after acetate metabolism (acetate dialysate), loss of carbon dioxide in dialyzer, rapid alkalinization of body fluids

20. Miscellaneous complications
Pruritis
Etiology is multifactorial (Xerosis, hyperparathyroidism, neuropathy, inadequate dialysis)
More severe during or after dialysis, may be allergic reaction to heparin, ethylene oxide, formaldehyde, acetate, dialysis membrane
Treatment ; Dialysis modification, treatment of hyperparathyroidism, topical emollients

21. Thank you