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  • Biomarkers of MIC such as serum albumin, CRP, IL6 and fetuin A were linked with increased mortality in hemodialysis patients
  • Biomarkers of myocardial injury and dysfunction
  • Plasma concentration of troponin T, BNP and NT pro BNP Predicted decreased survival and CVS events
  • Choose dry weight carefully
  • As fluid is removed during the dialysis procedure, the concentration of the hematocrit is detected by the optical sensor and can be graphed to reflect the increasing hematocrit. In addition, the cause for the concentration of hematocrit is the removal of fluid which is reflected by a change in total blood volume percent. Blood volume percent changes coordinate with Guyton’s Curve – AND reflect a mirror image of the changes occurring in the hematocrit. This mirror image is referred to as an inverse relationship.
  • Presentation2

    1. 1. Cardiovascular emergencies in dialysis patients Professor. Salwa Ibrahim, MD MRCP (UK) Cairo University
    2. 2. Agenda • Spectrum of CV emergencies in dialysis patients • Management
    3. 3. Acute Pericarditis
    4. 4. Uremic pericarditis • Pericarditis either before or within 8 weeks of initiating renal replacement therapy
    5. 5. Pathophysiology • Pericarditis arises from accumulation of biochemical irritants • Calcium alterations, high PTH, and uremic toxins have been blamed
    6. 6. Dialysis Related Pericarditis • Pericarditis after 8 weeks of renal replacement therapy May be secondary to Inadequate dialysis Volume overload Hypercatabolic conditions Hyperparathyroidism Infection (especially viral) •
    7. 7. Clinical Presentation • Chest Pain (41-100%) • Cough or dyspnea (31-57%) • Malaise (54-66%) • Weight Loss (40%) • Fever (75-100%)
    8. 8. Diagnosis • ECG does not show typical ST segment and T wave changes • Echo is used to assess the size of the effusion
    9. 9. Treatment • Uremic Pericarditis • Intensive HD or PD causes rapid improvement • Systemic anticoagulation should be avoided because of the high risk of hemorrhage
    10. 10. Dialysis Related Pericardial Effusion • Large (>250cc pericardial effusion, posterior echo free space more than 1cm) – Drainage • If hemodynamically unstable needs drainage • Medium and Small Effusions – Intensive Dialysis (5-7/week) – Serial monitoring by echocardiography
    11. 11. Ischemic Heart Disease
    12. 12. Risk factors of IHD in dialysis Traditional risk factors • Age • Male gender • Smoking • Family history • Hypertension • Diabetes mellitus • LVH Risk factors unique for dialysis • Anemia • Hyperpathyroidism • Uremia • Hyperphosphatemia • Malnutrition • Volume overload • AVF
    13. 13. K/DOQI • The K/DOQI guidelines recommend to screen ESRD for CVD at the start of dialysis 1. 2. 3. 4. ECG Echocardiography Coronary artery calcium scoring for selected cases Coronary angiography for revascularization candidates
    14. 14. How to manage Angina during dialysis session  History, physical examination, ECG and cardiac enzyme evaluation should be performed.  If dialysis is continued, the administration of oxygen and aspirin, reduction of the desired ultrafiltration and/or blood pump speed, and administration of nitrates or morphine
    15. 15. Prevention • Anemia management (Hb level 10.5-12.5g/dl) • Careful PRBCs transfusion if target not met • Gentle HD to avoid hypotension  Angina during dialysis may be prevented with the administration of nitrates and/or beta blockers prior to the treatment.  The efficacy of these agents is diminished since they commonly result in hypotension, thereby reducing the ability to effectively remove extracellular fluid.
    16. 16. 2013 Kidney Disease Global Outcomes (KDIGO) organization clinical practice guideline in on lipid management and treatment
    17. 17. Acute Myocardial Infarction • Acute MI is common among ESRD with poor outcome • Atherosclerosis/arteriolosclerosis contribute to LVH and increased myocardial oxygen demands and reduced coronary perfusion • Cardiac troponin is misleading in dialysis cases • Cardiac troponin I is more sensitive than cardiac troponin T or CK-MB
    18. 18. Management • Prevention : ASA/ clopidogrel, BB, ACEI and nitrates • Thrombolytics and glycoprotein IIb/IIIa antagonists are beneficial as in general population • LMWH is superior to UFH but likely to be associated with bleeding
    19. 19. Revascularization • CABG and angioplasty/ stenting should be considered in urgent cases as in general
    20. 20. Sudden death
    21. 21. Causes of death in the 4D (Die Deutsche Diabetes Dialyse) study Ritz, E. et al. J Am Soc Nephrol 2008;19:1065-1070
    22. 22. Epidemiology of sudden death in Dialysis • In the United States Renal Data System database 62% of cardiac deaths (or 27% of all deaths) are attributable to arrhythmic mechanisms. • Ventricular fibrillation/tachycardia were the predominant rhythm disturbance
    23. 23. Sudden Death • Two peaks  First few hours after the first HD of the week( rapid electrolyrte shifts)  Before the first HD of the week end of the long interval- (hyperkalemia)dead in bed syndrome Bleyer AJ et al: KI ( 2006) 69: 2268-2273
    24. 24. Risk factors for sudden death in dialysis patients LVH and heart failure Coronary artery calcification Abnormal myocardial structure and function fibrosis, microvessel disease Electrolyte shifts and hypervolemia (related to dialysis sessions) Hyperphosphatemia QT prolonging medication Sympathetic overactivity and autonomic nerve dysfunction
    25. 25. Low dialysate potassium is associated with the risk of sudden death
    26. 26. Low vitamin D is associated with the risk of SD
    27. 27. Management of cardiac arrest during dialysis • • • • • • • • Check responsiveness Open airway Check breathing Give 2 effectives breaths Check circulation Precordial thump Start CPR Attach defibrillator
    28. 28. Prevention of sudden death in dialysis
    29. 29. Prevention of sudden death • Routine very low potassium dialysate should be avoided • beta-blockers and (ACEIs) are proven therapies for reducing mortality in patients with congestive heart failure. • A small prospective randomized trial of carvedilol in 114 dialysis patients with dilated cardiomyopathy. • They found a significant reduction in CVS mortality and a trend toward reduction in sudden death • The largest prospective trial of ACEIs in dialysis patients, found no reduction in CVS events for fosinopril compared to placebo in prevention of sudden death
    30. 30. Implantable cardioverter defibrillators (ICDs) • Observational data suggest that for cardiac arrest survivors on dialysis, the benefit of ICD implantation is not attenuated by ESRD. • A 42% reduction in all-cause mortality for patients receiving ICDs, even after adjustment for comorbid illness. • The role of ICDs for primary prevention of sudden cardiac death in dialysis patients remains uncertain.
    31. 31. Arrhythmia
    32. 32. Cardiac Arrhythmias • Acute : Ventricular Tachycardia Ventricular Fibrillation
    33. 33. Acute Arrhythmias • Dialysis session should be terminated • Urgent Cardioversion as per ACLS Guidelines • Amiodarone –1stline drug: Ventricular Tachycardia
    34. 34. Intradialytic Hypotension
    35. 35. Definition • IDH is defined as a decrease in SBP by ≥20 mm Hg associated with symptoms that include: nausea; vomiting; restlessness; dizziness; and anxiety. • It can induce cardiac arrhythmias, predisposes to coronary and/or cerebral ischemic events.
    36. 36. Higher UF rates are associated with greater CV mortality
    37. 37. Etiology • • • • • • • • • • • • • Age, anemia Female Gender Presence of diabetes mellitus Hyperphosphataemia Presence of coronary artery disease Use of nitrates/antihypertensives Autonomic neuropathy Warm dialysate/acetate buffer Eating during sessions Pericardial effusion Septicemia Occult bleeding arrhythmia
    38. 38. Pathophysiology • Interplay of four factors 1. Ultra-filtration 2. Refill blood volume 3. Dialysate (Na+, Ca++, Temp) 4. Patient sensitivity to volume withdrawn
    39. 39. Prevention • Dry Weight Assessment • Clinical assessment , IVC diameter • BNP level • Echocardiography, ECG
    40. 40. Prevention • Intradialytic Blood Volume monitoring • Slow longer dialysis • Sequential UF/dialysis • Na+ > or equal 144mEq • Bicarbonate dialysate • Low temperature (36.5-35) • High dialysate calcium
    41. 41. Blood Volume Monitoring Measures hematocrit in arterial blood Crit-Line® Technology Blood volume change – surrogate marker for vascular refilling Increase in hematocrit relative to decrease in fluid removal
    42. 42. The Inverse Relationship between blood volume and hematocrit Not reliable in clinical studies
    43. 43. Treatment of IDH • Place patient head down • 100 cc bolus NS • Reduce UF to zero • Midodrine in refractory cases • 6-week Sertraline therapy (SSRI)
    44. 44. Air embolism
    45. 45. Air embolism  Fatal cause of chest pain and dyspnea during dialysis.  Disconnection of connecting caps and/or blood lines can lead to air embolism in patients being dialyzed with central venous catheters.  Foam in the venous blood line should raise the suspicion that air is entering the dialysis system.
    46. 46. Clinical manifestations  Symptoms of the air embolism depend upon the patient's position  In the seated patient, air tends to migrate into the cerebral venous system without entering the heart leading to loss of consciousness and seizure  Those who are recumbent, air tends to enter the heart and then the lungs leading to dyspnea, cough, chest pain
    47. 47. Management • Clamp the venous blood line • Stop the blood pump • Put the patient in the recumbent position on the left side with the chest and head titled downwards • Cardiorespiratory support • Supplemental Oxygen • Aspiration of air from the atrium/ventricle
    48. 48. Infective endocarditis
    49. 49. Clinical Presentation • Complication of catheter related bacteremia • MV/AV affection is common because of calcification • Fever, leucocytosis, new murmur
    50. 50. Management • Blood cultures/THE/TEE • Empirical therapy with vancomycin+aminoglycosides • Valve replacement (valve destruction, recurrent embolization, failure to respond)