Dr.Shrouk Al-Nagar Ass. lecturer MNDU

1. CVD IN HD

2. • 62 y- male, smoker 20 ys
• HTN , DM on insulin ,
• diabetic retinopathy , nephropathy 7 ys ago
• HD from A-V fistula 6m ago 3 sessions / week

3. onset of last HD session :
acute compressing retrosternal pain ,
nausea and dizziness

4. Fully conscious
BP : 90/60
Pulse : 100 / min
RR : 28 / min
Temp : 37º
Chest exam : BVB
Cardiac aus : NAD
NO edema LL

5. Next step?

6. • Trendelenburg position
• Pump 200 ml / min
• UF 0 ml/ hr
• O2
• Saline 0.9 % ( 200 cc)
• SL Nitrate

7. Still chest pain !

8. • Session terminated
• SL Nitrate
• ECG
• Cardiac enzymes
Troponin I : 0.05 ng /ml ( n : < 0.04 ng /ml)

9. POSSIBLE DIAGNOSIS ??

10. Chest pain during HD
• CVD
• PULMONARY
• GI
• MUSCULOSKELTAL
• OTHERS
Air embolism , tunneled catheter malposition
anaphylaxis

11. • Mortality due to CVD 10-30 > general populations
• CVM in 30y –old HD ptn = CVM in 80 y-old general
population
Why cvs ?

13. Diagnosis challenges
• Silent ischemia
• CKD patients → chronic minor elevation in troponin
• ECG
strain pattern → LVH
• Cardiac catheterization → RKF

14. Helpful clues
• Dynamic changes in ECG
• AHA :
Minor elevation of troponin → no injury
Acute rising or falling → acute MI
• Echo : segmental wall motion abnormality
• Angiography

15. Management

16. Risk factors Anti ischemic
Angioplasty &
CABG
Thrombolytic
&anticoagulants

17. 1- Risk factors

18. Risk factors
Traditional RF Non traditional RF
BP
DM
Smoking
Dyslipidemia
BMD
Anemia
Oxidative stress

19. Dyslipidemia
• Risk factors :
o Glucose absorption from peritoneal dialysate
o High CHO diet
o ↓ Lipoprotein lipase
o Heparin
o ↓ hepatic BFR
• Diagnosis :
KDIGO 2013
Measured at least once D ↑↑↑ Cholesterol ≥1000mg/dl
exclude 2ry causes

21. TTT

22.  RF :
• Exercise ,
• Alcohol avoidance,
• CHO restriction
• Salt restriction

23. •
 Statins :
Indications :
KDIGO 2013
o Statin , statin ezetimibe combinations shouldn’t be initiated in HD
PTN
″ Long life expectancy , recent ACS ″
o PTN already treated with statins should be continued
Caution :
o CYT P450 co -metabolism :
CNI ,macrolides, CCB ,antifungal, fibrates→ ↑ Bl level → myopathy

25.  Fibrates :
• Indications :
KDIGO 2013
Fibric acid derivatives not recommended to ↓ CV risk or prevent
pancreatitis in adults with CKD & hypertriglyceridemia
″ > 500 mg/dl balance between risks ″
• Caution :
o Avoid with statins
o Dose modification
( fenofibrate 100 mg/d)

26.  Others :
• Sevelamere : ↓ LDL cholesterol
• Necotinic acid : 1st line in ↑↑ TG
• Ezetimibe : limited data

27. 2-Anti ischemic drugs :
• ACEI : ?? Regression LVH
• BB carvedilol
• Nitrates
• Antiplatelet :
o conflicting reports that it worsen HF outcomes in patients with
CKD
o Bleeding
However ,
in HD PTN with CHD :
no sufficient evidence to recommend against its use

29. 3-Thrombolytics & anticoagulants
• LMWH :
o superior to UFH but high risk of bleeding
o Dose reduced
• Plt glycoptn 2b 3a :
o eptifibatide dose adjust
• Thrombolytics :
o given if indicated
o CI :
Catheter insertion 14 day
Recent renal biopsy
Active PU
Uremic Pericarditis
Uncontrolled HTN ( i.e. : > 220/110 )

30. 4-CABG & ANGIOPLASTY
• Dialysis before angioplasty
• Hemofilteration during CABG

31. Hyperhomocystinemia &
CVD IN HD

32. • Sulphur containing AA
• Normal : 5-10 Mmol / L
• Metabolism :

33. • RISKS :
General population studies : HHCY risk factor CVD
Whether this apply to ptn WITH RRT : unclear
Mechanism :
Activation of coagulation cascade
Endothelial damage ( oxidative stress , lipid peroxidation)

34. HHCY & dialysis PTN :
• 85 -100 % HD PTN
• Sever HHCY :
• >50 Mmol/L,
• rare ,
• non traditional risk factors for 50 % mortality from CVD

35. TTT

36. Can HD session precipitate MI?

37. • Hypersensitivity → Mast cell activation → coronary
→ MI

39. Back to CASE

40. Ptn was admitted for :
• Anti ischemic
• Echo : segmental ant wall hypokinesia
• Serial Troponin I : .09 ng/ml
• ECG :

41. • CORONARY Angiography :
o total occlusion of lt ant descending coronary artery
o all other vessels patent & EF 40 %
o Aspiration thrombectomy
o 2.5 *15 mm stent was implanted in diseased segment

42. Cardiomyopathy

43. • KIDOQI 2005 :
• ECHO at dialysis initiation after dry wt
→every 3 years
TTT :
• Euvolemia more important > drugs
• ACEI
• BB
• Spironolactone (k)
• Lanoxin ( .0625 -0.125 mcg/d)
• High flow fistula
• L –carnitine symptomatic resistant HF

44. Pericarditis

45. • TYPES :
Dialysis related
Uremic pericarditis
• Diagnosis :
• TTT :
Monitor > 100 cc
Intensification of dialysis 5-7 /w – heparin free
Drugs : NSAIDS –steroids not indicated
Surgical drainage : tamponade

46. Arrhythmia

47. • Acute :
Terminate session
Electrolytes
Hemodynamic unstable : cardioversion
• Chronic :
Rate , rhythm control :
BB ,CCB ,Digoxin, Amiodarone
Interaction () warfarin , amiodarone , digoxin
Anticoagulant : bleeding
calciphylaxis
2014 AHA warfarin → HD PTN , non valvular AF , CHAD-
VASC score > or = 2 + individualized

48. THANK YOU