Acute Complications of Acute Complications of HemodialysisHemodialysis
Director of Internal Medicine, Shuang-Ho Director of Internal Medicine, Shuang-Ho Hospital,Taipei Medical University; professor, Hospital,Taipei Medical University; professor,
Tri-Service General HospitalTri-Service General Hospital
Yuh-Feng Lin M.D.Yuh-Feng Lin M.D.
Intradialytic hypotensionIntradialytic hypotension Definition: A decrease in systolic BP ≥20 mm Hg or a Definition: A decrease in systolic BP ≥20 mm Hg or a
decrease in MAP ≥ 10 mm Hg associated with decrease in MAP ≥ 10 mm Hg associated with symptoms. symptoms.
Complication: cardiac arrhythmias, coronary and/or Complication: cardiac arrhythmias, coronary and/or cerebral ischemic eventscerebral ischemic events
Long-term side effects: volume overload due to Long-term side effects: volume overload due to suboptimal ultrafiltration, LVH, and interdialytic suboptimal ultrafiltration, LVH, and interdialytic hypertension hypertension
K-DOQI guildline
★
Risk Factors of Dialysis HypotensionRisk Factors of Dialysis Hypotension A thirdA third of dialysis patients of dialysis patients
Low Low body massbody mass
Poor nutritional status and Poor nutritional status and hypoalbuminemiahypoalbuminemia
Severe Severe anemiaanemia
Advanced Advanced age age (Age > 65 years old)(Age > 65 years old)
Cardiovascular Cardiovascular diseasedisease
Large interdialysis Large interdialysis weight gainweight gain
Low Low blood pressure blood pressure ((predialysis systolic BP <100 mm Hg)predialysis systolic BP <100 mm Hg)
Etiology of Dialysis Hypotension Etiology of Dialysis Hypotension (I)(I)
Excessive rate and degree of Excessive rate and degree of ultrafiltrationultrafiltration
Inappropriate peripheral venodilation Inappropriate peripheral venodilation
Autonomic dysfunctionAutonomic dysfunction
Inadequate vasoconstrictor secretionInadequate vasoconstrictor secretion
Etiology of Dialysis Hypotensoin (II)Etiology of Dialysis Hypotensoin (II)
Acetate dialysateAcetate dialysate
Low Low calciumcalcium dialysate dialysate
EatEat shortly before dialysis shortly before dialysis
AntihypertensiveAntihypertensive medications medications
LV dysfunctionLV dysfunction
UltrafiltrationUltrafiltration
Osmolality Osmolality FallFall
Warm Warm DialysateDialysate
Bio-incom-Bio-incom-patibilitypatibility
EndotoxinEndotoxin
AcetateAcetateInfusionInfusion
VolumeVolume
VasopressorsVasopressors
VasodilatatorVasodilatator
Cell Cell DysfunctionDysfunction
ComplementComplementActivation, Activation, Cytokine releaseCytokine release
HypoxemiaHypoxemia
Heart DiseaseHeart Disease
Vascular Vascular DiseaseDisease
Autonomic Autonomic DysfunctionDysfunction
Hormonal Hormonal DysfunctionDysfunction
MedicationsMedications
SepsisSepsisInfectionInfection
Vasovagal stim.Vasovagal stim.
HYPOTENSiONHYPOTENSiON
CARDIACCARDIACOUTPUTOUTPUT
PERIPHERAL PERIPHERAL RESISTANCERESISTANCE
PATHOGENESIS MEDIATORS PATHOPHYSIOLOGY PATIENT
Before DialysisBefore Dialysis After DialysisAfter Dialysis
TestTest NormotensiveNormotensive HypotensiveHypotensive Normotensive Normotensive HypotensiveHypotensive
Orthostasis (standing up)Orthostasis (standing up)
∆∆SBP (mmHg)SBP (mmHg) -3.7 ± 2.7-3.7 ± 2.7 -14.1 -14.1 ± 2.6*± 2.6* -6.0 ± 2.7-6.0 ± 2.7 -16.0-16.0 ± 3.1± 3.1††
∆∆DBP (mmHg)DBP (mmHg) --4.6 ± 1.64.6 ± 1.6 -11.5 ± 1.4*-11.5 ± 1.4* -4.3 ± 1.7-4.3 ± 1.7 -10.0 ± 1.7-10.0 ± 1.7††
30:15 ratio (normal 30:15 ratio (normal ≥ 1.04)≥ 1.04) 1.045 ± 0.021.045 ± 0.02 1.023 ± 0.0141.023 ± 0.014 1.036 ± 0.0151.036 ± 0.015 1.023 ± 0.0111.023 ± 0.011
Valsalva quotient (normal ≥ 1.21)Valsalva quotient (normal ≥ 1.21) 1.060 ± 0.0251.060 ± 0.025 1.024 ± 0.0141.024 ± 0.014 1.102 ± 0.0281.102 ± 0.028 1.012± 0.0291.012± 0.029††
Sustained handgrip (normal ≥Sustained handgrip (normal ≥ 15)15)
∆∆DBP (mmHg)DBP (mmHg) 5.8 ± 2.35.8 ± 2.3 7.1 ± 0.77.1 ± 0.7 7.2 ± 1.17.2 ± 1.1 6.8 ± 0.76.8 ± 0.7Cutaneous coldCutaneous cold
∆∆SBP (mmHg)SBP (mmHg) 6.8 ± 1.46.8 ± 1.4 7.1 ± 1.27.1 ± 1.2 5.9 ± 1.05.9 ± 1.0 5.6 ± 0.85.6 ± 0.8
∆∆DBP (mmHg)DBP (mmHg) 5.1 ± 1.35.1 ± 1.3 4.9 ± 1.44.9 ± 1.4 4.5 ± 0.94.5 ± 0.9 4.4 ± 0.74.4 ± 0.7
Table. Results of four tests of autonomic function in normotensive and hypotensive Table. Results of four tests of autonomic function in normotensive and hypotensive patients on maintenance hemodialysispatients on maintenance hemodialysis
Lin YF, Wang JY et al., ASAIO 39:946-953, 1993.Lin YF, Wang JY et al., ASAIO 39:946-953, 1993.
-15
-10
-5
0
5
-40 -30 -20 -10 0
BV
(%
)B
V (
%)
cGMP (pmol/ml)cGMP (pmol/ml)
Fig. Correlation between changes in blood volume and plasma Fig. Correlation between changes in blood volume and plasma cGMP throughout HD.cGMP throughout HD.
Wann GL. Lin YF. ASAIO 44:M569, 1998.Wann GL. Lin YF. ASAIO 44:M569, 1998.
0
10
20
30
40
50
60
70
80
Normotensive Hypotensive
Pla
sma
NO
Pla
sma
NO
22-- + N
O +
NO
33-- ( ( M
/l)M
/l)
Fig. Plasma levels of nitrite and nitrate in hypotensive Fig. Plasma levels of nitrite and nitrate in hypotensive and normotensive patients on hemodialysis.and normotensive patients on hemodialysis.
Lin SH. ASAIO J 42:M895, 1996.Lin SH. ASAIO J 42:M895, 1996.
Accurate Estimation of Dry Accurate Estimation of Dry WeightWeight
cGMPcGMP, , ANPANP
IVCDIVCD
Continuous monitoring of Continuous monitoring of BVBV
Bioimpedence ECF/TBWBioimpedence ECF/TBW
Prevention and Management Prevention and Management of Dialysis Hypotension (I)of Dialysis Hypotension (I)
Limiting Limiting sodiumsodium intake intake
Minimize interdialytic weight gain by educationMinimize interdialytic weight gain by education
Blood sugarBlood sugar control control
SlowSlow ultrafiltration ultrafiltration
SodiumSodium modeling modeling
Raise dialysate Raise dialysate calciumcalcium
Lower Lower dialysate temperaturedialysate temperature
Prevention and Management Prevention and Management of Dialysis Hypotension (II)of Dialysis Hypotension (II)
Switch to Switch to CAPDCAPD
Hyperoncotic Hyperoncotic albuminalbumin
Nasal Nasal oxygenoxygen
MannitolMannitol infusion infusion
Prevention and Management Prevention and Management of Dialysis Hypotension (III)of Dialysis Hypotension (III)
L-L-CarnitineCarnitine therapy therapy SertralineSertraline MidodrineMidodrine Blood transfusionBlood transfusion or or erythropoietinerythropoietin therapy therapy Volume expansionVolume expansion VasoconstrictorVasoconstrictor
00.2
0.4
0.6
0.8
1
1.21.4
1.6
1.8
Pre-Sertraline Sertraline
Nu
mb
er o
f H
ypot
ensi
ve e
pis
odes
Nu
mb
er o
f H
ypot
ensi
ve e
pis
odes
Fig. Number of hypotensive episodes per hemodialysis Fig. Number of hypotensive episodes per hemodialysis session in the sertraline and pre-sertraline periods.session in the sertraline and pre-sertraline periods.
Dheenan S. AJKD 31:624, 1998.Dheenan S. AJKD 31:624, 1998.
p < 0.005p < 0.005
-1 0 1 2 3 4 550
60
70
80
90
100
* *
*
*
*
Hours
MA
P (
mm
Hg
)
Figure. Serial changes in MAP HD before ( Figure. Serial changes in MAP HD before ( ) and after () and after ( )midodrine therapy. )midodrine therapy.
YF Lin et al. Am J Med Sci 2003;325:256-61.
Conclusion and clinical applicationConclusion and clinical application
Midodrine improves chronic hypotensin Midodrine improves chronic hypotensin
in HD patients by modulating in HD patients by modulating autonomic autonomic
functionfunction and its direct effects on and its direct effects on
peripheral vesselsperipheral vessels..
Without hypotensionWithout hypotension With hypotensionWith hypotension
Total carnitine (mml/l)Total carnitine (mml/l) 27.0 ± 2.727.0 ± 2.7 18.4 ± 2.218.4 ± 2.2**
Free carinitine (mmol/l)Free carinitine (mmol/l) 18.8 ± 2.018.8 ± 2.0 10.9 ± 1.710.9 ± 1.7****
Acyl/free carnitine ratioAcyl/free carnitine ratio 0.58 ± 0.060.58 ± 0.060.78 ± 0.150.78 ± 0.15
Table. Carnitine levels in patients with (n=8) and without Table. Carnitine levels in patients with (n=8) and without (n=23) (n=23) intra-dialytic hypotensionintra-dialytic hypotension
Values are mean ± SEM, * p < 0.05, ** p < 0.01 vs without hypotension Values are mean ± SEM, * p < 0.05, ** p < 0.01 vs without hypotension
Riley S. Clin Nephrol 48:392, 1997.Riley S. Clin Nephrol 48:392, 1997.
HypoxemiaHypoxemia
Alkali Alkali attenuate hyperventilationattenuate hyperventilation
AcetateAcetate dialysate dialysate
ComplementComplement activation activation
PulmonaryPulmonary leukosequestration leukosequestration
Actin polymerizationActin polymerization
BiocompatibleBiocompatible hollow fiber hollow fiber
Muscle CrampsMuscle Cramps 335-865-86%% of hemodialysis patientsof hemodialysis patients Lower extremitiesLower extremities Mechanisms: Rapid Mechanisms: Rapid ultrafiltration, ultrafiltration,
Intradialytic hypotension, tissue hypoxiaIntradialytic hypotension, tissue hypoxia Treatment: Quinine, Vit E, L-carnitine, Treatment: Quinine, Vit E, L-carnitine,
Creatine monohydrate, Creatine monohydrate, SodiumSodium modeling, hmodeling, hypertonicypertonic solution solution
Acute Allergic ReactionAcute Allergic Reaction First use syndromeFirst use syndrome
Burning retrosternal painBurning retrosternal pain
Diffuse heat, cold perspiration, urticaria, Diffuse heat, cold perspiration, urticaria,
pruritus, pruritus, laryngeal striderlaryngeal strider, ,
bronchospasmbronchospasm, loss of consciousness, loss of consciousness
Polyurethane function as a reservoir for Polyurethane function as a reservoir for
ethylene oxideethylene oxide
0
500
1000
1500
2000
2500
3000
0' 30' 120' 240'
HP
SCA
CA
PMMA
PS-E
Fig. Comparisons of serum C3a levels during hemodialysis Fig. Comparisons of serum C3a levels during hemodialysis procedure with different dialysis membrane.procedure with different dialysis membrane. (* p< 0.05, ** p<0.01 vs baseline)(* p< 0.05, ** p<0.01 vs baseline)
Ser
um
C3a
(n
g/m
l)S
eru
m C
3a (
ng/
ml) ****
**
****
0
1
2
3
4
5
6
7
8
0' 30' 120 240'
HPSCACAPMMAPS-EPS-S
Fig. Comparisons of WBC levels during hemodialysis Fig. Comparisons of WBC levels during hemodialysis procedure with different dialysis membrane.procedure with different dialysis membrane. (* p< 0.05, ** p<0.01 vs baseline)(* p< 0.05, ** p<0.01 vs baseline)
WB
C (
/cu
mm
)W
BC
(/c
um
m)
**
**
****
0
200
400
600
800
1000
1200
1400
1600
1800
2000
NC Before 15th min End
CuprophanPMA
Fig. Comparisons of TNF-Fig. Comparisons of TNF- production by zymoxan-stimulationed production by zymoxan-stimulationedMonocytes between Cuprophan and PMMA hollow fiber before, at the 15Monocytes between Cuprophan and PMMA hollow fiber before, at the 15 thth minute of and at the end of dialysis. NC= Normal control. minute of and at the end of dialysis. NC= Normal control. ** p<0.01 between two hollow fibers, +++ p<0.001 among three time periods.** p<0.01 between two hollow fibers, +++ p<0.001 among three time periods.
TN
F-
TN
F-
(pg
/ml/
2 x
10 (
pg/m
l/2
x 10
66 mon
ocyt
es)
mon
ocyt
es)
YF Lin. Am J Nephorl 16:293, 1996.YF Lin. Am J Nephorl 16:293, 1996.
Table. Clinical relevance of cytokine production in hemodialysis Table. Clinical relevance of cytokine production in hemodialysis patientspatients
AcuteAcute ChronicChronic
FeverFever AnemiaAnemiaSleep disordersSleep disorders Bone diseaseBone diseaseHypotensionHypotension MalnutritionMalnutrition
Immunological dysfunctionImmunological dysfunction
Pertosa G KI 58 suppl 76:S104, 2000.Pertosa G KI 58 suppl 76:S104, 2000.
0
50
100
150
200
250
0 20 40 60 80 100
IL-6 (ng/ml)
EP
O d
ose
(U/k
g/w
eek
)
Fig. Relationship between interleukin-6 (IL-6) production by Fig. Relationship between interleukin-6 (IL-6) production by peripheral blood mononuclear cells (PBMC) and erythropoietin peripheral blood mononuclear cells (PBMC) and erythropoietin (EPO) requirements in 34 hemodialysis subjects (r=0.384, p=0.039)(EPO) requirements in 34 hemodialysis subjects (r=0.384, p=0.039)
Goicoechea M KI 54:1337, 1998.Goicoechea M KI 54:1337, 1998.
0
10000
20000
30000
40000
50000
0' 30' 120' 240'
CAHPSCAPS-EPS-S
Fig. Comparisons of serum Fig. Comparisons of serum 2M during hemodialysis procedure with 2M during hemodialysis procedure with different dialysis membrane. (* p< 0.05 vs baseline)different dialysis membrane. (* p< 0.05 vs baseline)
****
**
**
Ser
um
S
eru
m
2 m
icro
glob
uli
n (
2 m
icro
glob
uli
n (
g/L
)g/
L)
Uremic Pruritus Uremic Pruritus (I)(I)
50-50-9090%% of dialysis patientsof dialysis patients
Risk: male, high serum BUN, Ca, P, Risk: male, high serum BUN, Ca, P, β2-β2-
microglobulin, dmicroglobulin, durationuration of dialysis of dialysis
Diagnositc criteriaDiagnositc criteria
★
PathogenesisPathogenesis
Pruritogenic substancePruritogenic substancemast cell release mast cell release histamine, IL-2, …histamine, IL-2, …cascade of nerve cascade of nerve conduction to induce in perception of itchconduction to induce in perception of itch
★
Uremic Pruritus Uremic Pruritus (II)(II)
Optimize the dialysis doseOptimize the dialysis dose
Treat anemiaTreat anemia
Treat 2nd hyperparathyroidism Treat 2nd hyperparathyroidism
Ultraviolet BUltraviolet B phototherapy phototherapy
Topical emollientsTopical emollients
CapsaicinCapsaicin
AntihistamineAntihistamine
Anti-serotonin agentsAnti-serotonin agents
★Topical treatmentTopical treatment
(a) Skin emollients(a) Skin emollients(b) Capsaicin(b) Capsaicin(c) Topical steroids(c) Topical steroids
Physical treatmentPhysical treatment(a) Phototherapy(a) Phototherapy(b) Acupuncture(b) Acupuncture(c) Sauna(c) Sauna
Systemic treatmentSystemic treatment(a) Low-protein diet(a) Low-protein diet(b) Primrose oil(b) Primrose oil(c) Lidocaine and mexilitine(c) Lidocaine and mexilitine(d) Opioid antagonists(d) Opioid antagonists(e) Activated charcoal(e) Activated charcoal(f) Cholestyramine(f) Cholestyramine(g) Serotonin antagonists(g) Serotonin antagonists(h) Parathyroidectomy(h) Parathyroidectomy(i) Nalfurafine(i) Nalfurafine
Table. Degree of pruritus on capsaicin therapyTable. Degree of pruritus on capsaicin therapy
Degree of pruritusDegree of pruritus NoneNone MildMild ModerateModerate SevereSevere
Before treatmentBefore treatment 00 00 88 99
After treatment After treatment ** 55 99 11 22
8 weeks postreatment8 weeks postreatment 44 55 55 33
Arrhythmia (I)Arrhythmia (I)
30-48%30-48% of dialysis patientsof dialysis patients
Risk factor: Risk factor:
▲▲ Compromised myocardium: CAD, Compromised myocardium: CAD,
Intermyocardiocytic fibrosis, Intermyocardiocytic fibrosis,
Pericarditis Pericarditis
▲▲ Increased QT interval or dispersionIncreased QT interval or dispersion
★
Arrhythmia Arrhythmia (II)(II)
▲▲ Electrolyte imbalance: hypokalemia, Electrolyte imbalance: hypokalemia,
hyperkalemia, hypercalcemia, hyperkalemia, hypercalcemia,
hypermagnesemiahypermagnesemia
▲▲ AnemiaAnemia
▲▲ Increased Increased LV massLV mass
▲▲ Advanced ageAdvanced age
▲▲ AcetateAcetate dialysate dialysate
★
350
400
450
500
0
P < 0.001
Fig. Distribution of QTc values among hemodialysis patients and controls. The mean value of QTc was significantly increased in hemodialysis patients (432.6 ± 24.9 ms) compared controls (402.0 ± 21.0 ms) (p<0.01)
Suzuki R. Clin Nephrol 49:240, 1998.
Contol(n=30)
HD(n=42)
Table. Independent predictors of QTc interval by multivariate Table. Independent predictors of QTc interval by multivariate stepwise regression analysisstepwise regression analysis
VariableVariable CoefficientCoefficient Standard errorStandard error T valueT value P valueP value
Diabetes mellitusDiabetes mellitus 25.77325.773 6.2036.203 4.1554.155 0.00020.0002
Ejection fraction Ejection fraction -111.18-111.18 42.54642.546 -2.613-2.613 0.01270.0127
(Constant)(Constant) 494.6494.6 28.92928.929 17.09717.097
Independent factor: QTc interval Independent factor: QTc interval RR22 = 0.497 = 0.497
Suzuki R. Clin Nephrol 49:240, 1998.Suzuki R. Clin Nephrol 49:240, 1998.
Results of 24-Hour Holter ECG MonitoringResults of 24-Hour Holter ECG Monitoring
Arrhythmias SeenArrhythmias Seen No. of Tapes (%)No. of Tapes (%)
Ventricular ectopic beats (> 20/hr)Ventricular ectopic beats (> 20/hr) 15 (24)15 (24)
Ventricular ectopic beats (> 100/hr)Ventricular ectopic beats (> 100/hr) 2 (3) 2 (3)
Episodes of ventricular tachycardiaEpisodes of ventricular tachycardia 5 (8) 5 (8)
Epidoses of supraventricular tachycardiaEpidoses of supraventricular tachycardia 2 (3) 2 (3)
Episodic atrial fibrillation Episodic atrial fibrillation 7 (11) 7 (11)
Heart block (intermittent)Heart block (intermittent) 1 (1.6) 1 (1.6)
Jassal SV AJKD 30:219, 1997.Jassal SV AJKD 30:219, 1997.
Bleeding During Dailysis Bleeding During Dailysis (I)(I)
Platelet dysfunctionPlatelet dysfunction
Impaired dense granule release of Impaired dense granule release of ATPATP and and
serotoninserotonin
Reduced synthesis of Reduced synthesis of thromboxanethromboxane A2 A2
Elevated platelet cytosolic cAMP and calcium Elevated platelet cytosolic cAMP and calcium
Impaired Impaired aggregationaggregation response response
Bleeding During Dialysis Bleeding During Dialysis (II)(II)
Altered adhesive Altered adhesive fibrinogenfibrinogen and and vWf vWf
Impaired fibrinogen receptor Impaired fibrinogen receptor (GPIIbIIIa)(GPIIbIIIa)
function function
Uremic toxin or inhibitorsUremic toxin or inhibitors
ErythropoietinErythropoietin augments GPIIbIIIa augments GPIIbIIIa
Bleeding During Dialysis Bleeding During Dialysis (III)(III)
Pack RBCPack RBC
Cryoprecipitate, FFP(VIII/vWF)Cryoprecipitate, FFP(VIII/vWF)
dDAVPdDAVP
EstrogenEstrogen
Air EmbolismAir Embolism 1 1 ml/kgml/kg air may be fatal air may be fatal
Occlude RV outflow tract and Occlude RV outflow tract and pulmonary pulmonary
vascularvascular bed bed
Thromboxane B2, endothelinThromboxane B2, endothelin
TrendelenburgTrendelenburg position with position with left sideleft side down down
Withdrawal of air from Withdrawal of air from RARA
Hyperbaric oxygenHyperbaric oxygen
Dialysis Pericarditis IDialysis Pericarditis I Uremic pericarditisUremic pericarditis: pericarditis before RRT or within : pericarditis before RRT or within
8 weeks of its initiation.8 weeks of its initiation.
Dialysis pericarditisDialysis pericarditis: : ≥≥ 8 weeks after initiation of RRT. 8 weeks after initiation of RRT.
Incidence of dialysis pericarditis: 2-12%Incidence of dialysis pericarditis: 2-12%
Etiology: inadequate dialysis, volume overload, Etiology: inadequate dialysis, volume overload,
infection, autoimmune, drugsinfection, autoimmune, drugs
★
Precordial pain, hypotension, dyspnea, fever, Precordial pain, hypotension, dyspnea, fever,
weight gainweight gain
Heparin freeHeparin free dialysis dialysis
Intensive dialysisIntensive dialysis
NSAIDNSAID
Subxiphoid pericardiostomySubxiphoid pericardiostomy
Dialysis Pericarditis Dialysis Pericarditis IIII
Dialysis Disequilibrium Dialysis Disequilibrium (I)(I)
Headache, vomiting, seizure, delirium Headache, vomiting, seizure, delirium
Rapid correctionRapid correction of marked azotemia of marked azotemia
Cerebral swellingCerebral swelling
Reverse ureaReverse urea effect effect
AcidosisAcidosis of the CSF of the CSF
Dialysis Disequilibrium Dialysis Disequilibrium (II)(II)
Inefficient dialysisInefficient dialysis
Shorten the durationShorten the duration
Lower dialyzer Lower dialyzer blood flowblood flow
Less efficientLess efficient dialyzer dialyzer
Osmotic agentsOsmotic agents, high sodium , high sodium
IV diazepam IV diazepam
Metabolic DisordersMetabolic Disorders
Metabolic alkalosisMetabolic alkalosis
Sodium citrateSodium citrate
Falty delivery of a buffer baseFalty delivery of a buffer base
FluorideFluoride poisoning poisoning
Acute Acute cuppercupper intoxication intoxication
Sodium DisordersSodium Disorders ConductivityConductivity limits are not adjusted limits are not adjusted
WaterWater intoxication intoxication
HyperkalemiaHyperkalemia
Metabolic Metabolic acidosisacidosis
Correction of hyponatremiaCorrection of hyponatremia
Drink water, Drink water, 5% G/W5% G/W for hypernatremia for hypernatremia
HypokalemiaHypokalemia Loss into dialysate, alkali therapy Loss into dialysate, alkali therapy
Renal or extrarenal lossesRenal or extrarenal losses
ArrhythmiaArrhythmia, hypotension, fatigue, weakness, , hypotension, fatigue, weakness,
paralysisparalysis
CADCAD, , digitalisdigitalis, , hypercalcemiahypercalcemia, , hypomagnesemiahypomagnesemia, ,
meta alkalosismeta alkalosis
Adjust Adjust dialysate potassiumdialysate potassium and buffer and buffer
HyperkalemiaHyperkalemia
Dietary intakeDietary intake
GI bleedingGI bleeding
Overheated or hypotonic dialysateOverheated or hypotonic dialysate
Chloramine, sodium hypochlorite, fluorideChloramine, sodium hypochlorite, fluoride
MedicationsMedications
Metabolic acidosisMetabolic acidosis
HypophosphatemiaHypophosphatemia Intensive Intensive dialysisdialysis
Phosphorus bindersPhosphorus binders
Reduced intakeReduced intake
Dysfunction of erythrocytes, CNS, skeletal Dysfunction of erythrocytes, CNS, skeletal
and cardiac muscleand cardiac muscle
PhosphorusPhosphorus rich food rich food
Hypercalcemia (I)Hypercalcemia (I)
Liberation of Liberation of calciumcalcium from bone from bone
Intradialytic gainIntradialytic gain
Phosphorus bindersPhosphorus binders
Widespread use of Widespread use of calcitriolcalcitriol
AluminumAluminum poisoning poisoning
Hypercalcemia (II)Hypercalcemia (II)
Low dialysate calciumLow dialysate calcium
Phosphorus binders Phosphorus binders during mealsduring meals
Discontinue Discontinue vitamin Dvitamin D Therapy Therapy
Treat aluminum toxicityTreat aluminum toxicity
PamidronatePamidronate
Fluoride ContaminationFluoride Contamination
Faulty RO and deionizationFaulty RO and deionization
Bring down Bring down calciumcalcium and and magnesiummagnesium
Vomiting, abdominal pain, cardiac irritabilityVomiting, abdominal pain, cardiac irritability
Muscle twitchingMuscle twitching, tetany, petechiae bleeding, tetany, petechiae bleeding
Respiratory failureRespiratory failure, hypotension, cardiac arrest, hypotension, cardiac arrest
Metabolic, respiratory Metabolic, respiratory acidosisacidosis
Chloramine ContaminationChloramine Contamination
Less than Less than 0.1 mg/L0.1 mg/L
Oxidize hemoglobin to form Oxidize hemoglobin to form
methemoglobinmethemoglobin
Appropriate Appropriate charcoal filterscharcoal filters
Vitamin CVitamin C
EndotoxinEndotoxin Bacterial infectionsBacterial infections
Bicarbonate Bicarbonate dialysate conc.dialysate conc.
Endogenous pyrogensEndogenous pyrogens
Header syndromeHeader syndrome
Disinfection of the Disinfection of the O ringsO rings
BackfiltrationBackfiltration with high flux dialysis with high flux dialysis
Hypertensive Emergencies Hypertensive Emergencies
Paradoxical, hypertensive responseParadoxical, hypertensive response
Rise in plasma Rise in plasma catecholaminecatecholamine
Activation of Activation of renin-angiotensinrenin-angiotensin system system
Antihypertensive withdrawalAntihypertensive withdrawal
Sublingual Sublingual captoprilcaptopril and and nifedipinenifedipine
Bowel IschemiaBowel Ischemia Abdominal pain, acute diarrheaAbdominal pain, acute diarrhea Dialysis hypotensionDialysis hypotension Digitalis, Digitalis, blockers blockers Occlusive and non-occlusive infarction Occlusive and non-occlusive infarction (25 to 60%)(25 to 60%) Congestive heart failureCongestive heart failure Cardiac Cardiac arrhythmia arrhythmia (esp. AF)(esp. AF) ESRDESRD Hyperkalemia, acidemia, leukocytosisHyperkalemia, acidemia, leukocytosis elevated elevated LDHLDH and and CPKCPK
Table. Location of Mesenteric InfarctionTable. Location of Mesenteric Infarction
LocationLocation No. of Patients (n=12)No. of Patients (n=12)Small bowelSmall bowel 11
ColonColon 11
CecumCecum 22
SigmoidSigmoid 33
Ileocecal and distal transverseIleocecal and distal transverse
coloncolon 11
Diffuse involvementDiffuse involvement
Small bowelSmall bowel 11
Large bowelLarge bowel 11
Small and large bowelSmall and large bowel 11
Distal ileum and right colonDistal ileum and right colon 11
Diamond SM. JAMA 256:2545, 1986.Diamond SM. JAMA 256:2545, 1986.
Table. Pertinent History and Medications (I)Table. Pertinent History and Medications (I)
Clinical CharacteristicClinical Characteristic Bowel InfarctionBowel Infarction ControlsControls
Heart diseaseHeart disease
Coronary artery diseaseCoronary artery disease 77 88
By conornary angiographyBy conornary angiography 44 33
AnginaAngina 55 44
Myocardial infarctionsMyocardial infarctions 22 11
Congestive heart failureCongestive heart failure 22 11
Atrial arrhythmiasAtrial arrhythmias 33 22
Diabetics with heart diseaseDiabetics with heart disease 22 33
Diamond SM. JAMA 256:2545, 1986.Diamond SM. JAMA 256:2545, 1986.
Table. Pertinent History and Medications (II)Table. Pertinent History and Medications (II)
Clinical CharacteristicClinical Characteristic Bowel InfarctionBowel Infarction ControlsControls
Cardiac medications, No. of patientsCardiac medications, No. of patients 66 55
DigoxinDigoxin 33 11
-Blockers-Blockers 22 11
Calcium antagonists Calcium antagonists 33 44
Episodes of hypotension when Episodes of hypotension when 44 33
undergoing dialysis undergoing dialysis
Frequent and/or severe hypotensionFrequent and/or severe hypotension 44 1 1
when undergoing dialysiswhen undergoing dialysis **
Diagnosis of severe atherosclerosisDiagnosis of severe atherosclerosis 33 11
Diamond SM. JAMA 256:2545, 1986.Diamond SM. JAMA 256:2545, 1986.
Table. Laboratory Values in Bowel Infarction GroupTable. Laboratory Values in Bowel Infarction Group
FindingsFindings No. of Patients (n=12)No. of Patients (n=12)White blood cell countWhite blood cell count
> 15 000 mm> 15 000 mm33 ( >15 x 10 ( >15 x 1099 /L) /L) 22> 20 000 mm3 ( > 20 x 10> 20 000 mm3 ( > 20 x 1099 /L) /L) 66
HematocritHematocritIncrease by 10% (0.10)Increase by 10% (0.10) 11Increase by 20% (0.20)Increase by 20% (0.20) 33
pHpH< 7.1< 7.1 44< 7.2< 7.2 117.2-7.357.2-7.35 227.35-7.457.35-7.45 22
Potassium, mEq/L (mmol/L)Potassium, mEq/L (mmol/L)> 7.0> 7.0 44> 5.0> 5.0 22
Bicarbonate, mEq/L(mmol/L)Bicarbonate, mEq/L(mmol/L)< 10< 10 55< 15< 15 11< 20< 20 44
Diamond SM. JAMA 256:2545, 1986.Diamond SM. JAMA 256:2545, 1986.