First few session care
PANTIPA TONSAWAN, M.D.
July 5, 2013
Scope
 Relation : ESRD , HD & death
 Pre HD patient evaluation
 HD prescription (initial treatment)
 HD complication (Initial treatment)
Impact : ESRD,HD & death
Probability
Probability of sudden cardiac death
in incident dialysis patients
Month after dialysis
USRDS 2012 ADR
U.S. Renal Data System, USRDS 2012 Annual Data Report
Causes of death :
prevalent dialysis patients, 2008–2010
ESRD pt
Cardiac causes
U.S. Renal Data System, USRDS 2012 Annual Data Report
USRDS 2012 ADR
Rates of sudden cardiac death : age
Period prevalent dialysis patients, age 20 & older, unadjusted.
USRDS 2012 ADR
U.S. Renal Data System, USRDS 2012 Annual Data Report
Death /1000 patient years
Rates of sudden cardiac death
prevalent dialysis patients, by primary diagnosis
2000
USRDS 2012 ADR
2005
2010
U.S. Renal Data System, USRDS 2012 Annual Data Report
Rates of sudden cardiac death following
initiation of treatment in incident HD patients
Death /1000 patient years
0-90 days : 1/10
2000
2006
2007
2007
2009
U.S. Renal Data System, USRDS 2012 Annual Data Report
USRDS 2012 ADR
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
Vascular
access
Hemodialysis
prescription
Patient
information
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
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
Vascular access : initial use
Arteriovenous fislula
Prepare : 3-6 mo
….. Maturation
Prompt ?
Arteriovenous graft
Prepare : 3-6 wk :
at least 2 wk after Surgery
HD catheter
immediately use
..complication ?
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 … Lite
Anti-coagulant : heparinloading..,maintenance …
(หรือnon-heparin ตามความเหมาะสม)
 50 % glucose 50-100 ml intra HD
(พิจารณาตามความเหมาะสมของผูป้ ่ วยแตละราย)
่
Daugirdas JT. Acute & Chronic hemodialysis prescription; Handbook of dialysis 2007
HD prescription (initial treatment)
 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)
Daugirdas JT. Acute & Chronic hemodialysis prescription; Handbook of dialysis 2007
HD prescription (initial treatment)
 Dialysate composition :
Na
145
Acute
Chronic 135-145
K
2, 3, 4
2,3
Ca
3.5
2.5
HCO3
25
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
Hemodialysis complications
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 3 2008 pp. 493–498
Dialysis disequilibrium syndrome
ICF
Brain
Urea
Urea↑
High
Osm
ECF
I
Urea
CF :
brain
H2O
IVF
ICF
Urea
:
bra
in
Urea
H20
slow
Reverse osmotic shift
Cerebral edema
HD
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 3 2008 pp. 493–498
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 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
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
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
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.
Dialyzer reaction
Type A : anaphylactic type
Type B :non-specific
 Full brown, Severe reaction
Firstafter
useHD…but
syndrome
 Common : 5 min
delayed 30 min
 Cause : ETO oxide, AN 69 reaction, contaminated
dialysis solution, reuse
Management :
Safest to stop dailysis, without returning blood
 Cardiorespiratory support
Prevention : proper rinsing, y-irradiated or streamsterilized dialyzer
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
Post HD care
Complication
Next session HD
USRDS 2012 ADR
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