1. PANTIPA TONSAWAN, M.D. July 5, 2013
First few session care
PANTIPA TONSAWAN, M.D.
July 5, 2013

2. Scope  Relation : ESRD , HD & death  Pre HD patient evaluation
 HD prescription (initial treatment)
 HD complication (Initial treatment)

3. Impact : ESRD,HD & death

4. Probability of sudden cardiac death in incident dialysis patients
Month after dialysis
U.S. Renal Data System, USRDS 2012 Annual Data Report

5. Causes of death : prevalent dialysis patients, 2008–2010
ESRD pt
Cardiac causes
U.S. Renal Data System, USRDS 2012 Annual Data Report

6. Rates of sudden cardiac death : age
Period prevalent dialysis patients, age 20 & older, unadjusted.
U.S. Renal Data System, USRDS 2012 Annual Data Report

7. U.S. Renal Data System, USRDS 2012 Annual Data Report
Rates of sudden cardiac death prevalent dialysis patients, by primary diagnosis
Death /1000 patient years
2000
2005
2010
U.S. Renal Data System, USRDS 2012 Annual Data Report

8. U.S. Renal Data System, USRDS 2012 Annual Data Report
Rates of sudden cardiac death following initiation of treatment in incident HD patients
0-90 days : 1/10
Death /1000 patient years
2000
2006
2007
2007
2009
U.S. Renal Data System, USRDS 2012 Annual Data Report

9. Caution !!! : sudden cardiac death
 RRT : Hemodialysis
 Aging : Exp > 65 yrs…>75 yrs
 Underlying : DM, HT
 Duration initial treatment :
0-90 days

10. Patient evaluation

11. Hemodialysis prescription
Pre HD Evaluation
Vascular
access
Hemodialysis prescription
Patient information

12. Patient information 1.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

13. Patient information 2.Laboratory data
 CBC :
 Hb/HCT, Platelet…..risk bleeding
 BUN/Cr :
 High BUN…..Risk ….DDS
 Electrolyte :
 Select : Dialysate solution component
 Serology:
 HBV, HCV, HIV…..isolated

14. Vascular access : initial use Arteriovenous fislula
Prepare : 3-6 mo
….. Maturation
Prompt ?
Arteriovenous graft
Prepare : 3-6 wk :
at least 2 wk after Surgery
Infection ?
HD catheter
Exit site, redness, warm
immediately use
..complication ?

15. Hemodialysis prescription

16. 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 … Lite
Anti-coagulant : heparinloading..,maintenance …
(หรือnon-heparin ตามความเหมาะสม)
 50 % glucose ml intra HD
(พิจารณาตามความเหมาะสมของผู้ป่วยแต่ละราย)
Daugirdas JT. Acute & Chronic hemodialysis prescription; Handbook of dialysis 2007

17. HD prescription (initial treatment)
 Time: initial 2 hr… ↑ 30 min q HD
……until 4 hr
 BFR : initial ml/min …↑ 30 min q HD
……until ml/min
 Dialyzer : initial low flux, low SA ….
(AIM ….Kt/V , URR 40 %)
 DFR : 500 ml/min …800ml/min (high BFR)
Daugirdas JT. Acute & Chronic hemodialysis prescription; Handbook of dialysis 2007

18. HD prescription (initial treatment)
 Dialysate composition : Na K Ca
HCO3
Acute
145
2, 3, 4
3.5 25
Chronic
2,3
2.5 32
 Temp. : low temp prevent Hypotension 36.5 C
 UF : < 1 L /hr, ….if need…sequential HD
 Hypertonic solution : 50 % glucose ….DDS
 Anticoagulant : depend on patient. condition
Daugirdas JT. Acute & Chronic hemodialysis prescription; Handbook of dialysis 2007

19. Hemodialysis complications

20. Dialysis disequilibrium syndrome
Acute neurological complication Consequence 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) ….
Pediatr Nephrol (2012) 27:2205–2211
Seminars in Dialysis—Vol 20, No pp. 493–498

21. Dialysis disequilibrium syndrome
ICF
ECF
IVF I
Urea
CF : brain
ICF : brain
Brain
Urea
Urea
H2O
Urea↑
High Osm
Urea
H20
slow
Reverse osmotic shift HD
Cerebral edema

22. Dialysis disequilibrium syndrome
Clinical : fatigue, mild headache, nausea, vomiting, disturbed consciousness, convulsions… coma.
Common mild..Self limited, fatal.. if severe
Diagnosis
Clinical diagnosis (during HD, after HD)
+ risk factor Exclusion other condition
Treatment
Symptomatic treatment/ hypertonic solution/ + stop HD
Seminars in Dialysis—Vol 20, No pp. 493–498

23. Dialysis disequilibrium syndrome
Prevention
Most important
 Dialysis time (2 hours)
Blood flow rate 200 ml/min
 Less efficient (small) dialyzer
 Hypertonic solution
 A goal URR : 0.4–0.45 or diffusive Kt/V of 0.6–0.7
Seminars in Dialysis—Vol 20, No pp. 493–498

24. Cardiac arrhythmia, Ischemia, sudden death
 DIALYSIS-INDUCED MYOCARDIAL STUNNING
Echocardiogram
- Pre HD …normal
- During HD …. RWMA abnormality
- Post HD 30 min …normal
Semin Dial 2007; 20: 220–228
 Positron emission tomography :
Measure ..MBF dialysis …..
HD precipitates reductions MBF
CAG …..normal
Clin J Am Soc Nephrol 2008; 3: 19–26.
Effects of hemodialysis on cardiac function
;Kidney International (2009) 76, 371–375

25. Cardiac arrhythmia, Ischemia, sudden death
 DIALYSIS-INDUCED CARDIAC ISCHEMIA
Myocardial stunning :
Occur ….60 %
Related to UF (total/rate )
& HD instability
Long term
High mortality
PET
Effects of hemodialysis on cardiac function
;Kidney International (2009) 76, 371–375

26. Intradialytic hypotension
Initial treatment : associated cause
High UF rate : limit time
Trial & error : set DW
High dose : anti HT
Nutrition status : malnutrition …low plasma refilling
Treatment  Sequential HD
 Limit IDWG < 1 kg/day
 Decrease anti HT ….decrease DW
 Avoid : eating during HD
 low Temp.

27. Type A : anaphylactic type
Dialyzer reaction
Type A : anaphylactic type
Type B :non-specific
 Full brown, Severe reaction
 Common : 5 min after HD…but delayed 30 min
 Cause : ETO oxide, AN 69 reaction, contaminated dialysis solution, reuse
First use syndrome
Management :
Safest to stop dailysis, without returning blood
 Cardiorespiratory support
Prevention : proper rinsing, y-irradiated or stream-sterilized dialyzer

28. Dialyzer reaction  Supportive care
Type B :non-specific
 Mild symptoms : chest pain, back pain
 Onset min after HD
 Cause : unknown
Management :
 Supportive care
 Differential diagnosis : coronary artery disease

29. Post HD care
Complication
Next session HD

30. 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