Yuh-Feng Lin MDYuh-Feng Lin MD

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

★

Causes of itching in ESRDCauses of itching in ESRD★

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

κ-opoid receptor agonist-κ-opoid receptor agonist-NalfurafineNalfurafine

★

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.

Thank You Thank You for your for your attentionattention

Yuh-Feng Lin M.D.