A Short-Term Single-Center-Based study

1. Urgent Hemodialysis Sessions
Impacts and Outcome
A Short-Term Single-Center-Based study
By
Omar Mahmoud Mohamed Kamal Ahmed
Supervised by:
Prof. Nagy Abdel-Hady Sayed-Ahmed
2019

2. Kidney Function
Purifying blood by removing waste and
excess fluid from the body
 Blood pressure control and electrolyte level
regulation e.g. [Na] and [K] and keep the AB
balance.
 Activation of vitamin D → improves the
absorption of Ca & P.
Introduction

3. •When kidneys fail,
DIALYSIS is needed
to keep the body in
balance.
Introduction

4. Dialysis is an artificial replacement of lost kidney function by
removing waste products and excess fluid from the blood
Hemodialysis
CKD
Elective RRT
Urgent RRT
(Compelling clinical
problems)
AKI Urgent RRT
(Acute fall in GFR)
Introduction

5. Urgent Indications of Hemodialysis
• Pulmonary edema
• Hyperkalemia
• Metabolic acidosis
• Uremic encephalopathy
• Uremic pericarditis
• Uremic bleeding
• Intractable vomiting or itching
• Severe hypercatabolism
• Dialysable intoxication
Whether for AKI or CKD
Introduction

6. Aim of the study
The aim of the current study is to evaluate urgent
hemodialysis sessions, of different indications and their
relation to the patients' final outcome.
Aim

7. Mansoura University Nephrology & Dialysis Unit
(MNDU)
Study Place
MNDU is served by:
• 18 nursing members
• 6 workers
• 4 engineering technicians
• 3 resident physicians supervised
by higher faculty medical staff.

8. • Study Design:
The current study has adopted a prospective observational technique.
Study Place
23 Hemodialysis
machines
HCV
16
HCV negative
5
HCV positive
Unresolved viral
markers
2

9. 4 Groups
AKI
AKI on
top of
CKD
ESRD first
discovered
ESRD on
RRT
• Included:
All patients admitted to the
MNDU in the 2-week study
period, in urgent need for non-
routine hemodialysis sessions.
• Study duration: 14 days
• Follow-up: until disposed-off
the unit
Patients

10. All patients were subjected to
• History Taking & Clinical Examination
• Lab (Routine):
• S. creatinine & Urea
• S. Na, K+ , pH, HCO3, PCO2 , Ca and PO4
• CBC and Liver function test.
• Virology :(ELISA) HCV, HIV, HBV. (No recorded cases with HBV or HIV).
• Renal Ultrasonography
Before 1st HD
session
Method

11. Important Study Variables
1. The indications to start urgent dialysis
2. Diagnosing: Preliminary & Subsequent
3. The number of hemodialysis sessions
4. Intradialytic Specifications
5. Complications during HD sessions.
6. Fate of Patients
Method

12. Outcome of Patients
1. Improvement: No further need of dialysis
2. Stationary: Continue on dialysis after discharge
3. Death or Deterioration (ICU admission).
Method

13. N= 30 patients
15 female - 15 male
 25% < 48 yrs old
 25% > 60 yrs old
 50% 48 - 60 yrs old
Results

14. Study Population Descriptive: Age and biochemical variables
*Ca level is measured in only 20 patients
Maximum
Minimum
SD
Mean
80
32
12.3
54.3
Age
31.7
2.9
5.8
10.9
Creatinine (mg/dL)
9.4
2.4
1.5
4.4
K+(mmol/L)
7.4
6.9
0.1
7.3
pH
24
3.6
5.5
16.5
HCO3 (mmol/L)
46.4
19
7.5
31.8
PCO2 (mmHg)
13.4
5.3
1.9
7.9
Hemoglobin (gm/dL)
182
61.7
19.6
86.1
MCV (fL/red cell)
594
27
121.3
215.3
PLT(billion/L)
26.1
2.2
6.01
10.8
WBC (billion/L)
11
5
1.4
8.4
Ca+2*(mg/dL)
150.7
115.2
7.3
134.3
Na+(mmol/L)
Results

15. 30 patients
7
AKI
10
ESRD
3
ESRD
on CHD
10
AKI on
CKD
Renal Diagnosis Groups
(Preliminary Diagnosis)
Results

16. 0
2
4
6
8
10
12
ESRD on CHD
ESRD
AKI on CKD
AKI
female
male
Gender Distribution in Renal Diagnosis Groups
Results

17. Results
0
5
10
15
20
25
30
35
Urgent Dialysis Indications
33%
10%
83%
43%
13%
7%

18. Comorbidities
None
TUMOR
LIVER
DISEASE
IHD
DM
HTN
3
3
0
0
2
4
AKI (n=7)
2
0
2
2
5
6
AKI on CKD (n=10)
1
0
1
0
6
8
ESRD (n=10)
1
0
0
0
2
2
ESRD on CHD (n=3)
7
3
3
2
15
20
Total no. (n=30)
3 pts with AKI had malignancy; 1 male had bladder cancer on
radiottt, 1 had lymphoma and 1 female had cancer uterus.
Results

19. • No cases had HBV or HIV
Frequency of HCV in the studied patients
%77
%23
Hepatitis C in urgent dialysis patients
HCV negative
HCV positive
N=7
Results

20. The number dialysis sessions
0
1
2
3
4
5
6
7
ESRD on Dx
ESRD
AKI on CKD
AKI
FREQUENCY OF DIALYSIS
2 or less
3 or more
Results
• ≤2: n=16
• ≥3: n=13
• + 1 pregn. lady

21. 30 patients
4
AKI
12
ESRD
3
ESRD
on CHD
11
AKI on
CKD
Renal Diagnosis Groups
(Discharge Diagnosis)
Results

22. Discharge vs Preliminary Diagnosis
Preliminary
Diagnosis
Discharge Diagnosis
AKI (n=4)
AKI on CKD
(n=11)
ESRD (n=12)
ESRD on CHD
(n=3)
AKI (n=7)
4 2 1 0
AKI on CKD
(n=10) 0 9 1 0
ESRD (n=10)
0 0 10 0
ESRD on CHD
(n=3) 0 0 0 3
Results

23. Patients' final outcome:
Died
Stationary on
Dialysis
Improved
25%
0
75%
AKI (n=4)
9.1%
72.7%
18.2%
AKI on CKD (n=11)
0
100%
0
ESRD (n=12)
0
100%
0
ESRD on CHD (n=3)
6.6%
76.7%
16.7%
Total (n=30)
• One patient died because of massive rectal bleeding
• One deteriorated in the ICU and died out of persistent septic shock
Results
2
23
5
0
5
10
15
20
25
Died
StatIonary on
dialysis
Improved
Final outcome

24. Initiation of urgent Hemodialysis does not
necessarily depend on definite diagnosis
•The decision to refer to urgent hemodialysis is usually
based on initial assessment (preliminary diagnosis):
delay for final diagnosis is not permissible.
•Attaining final diagnosis would not change the initial
plan but might modify long-term management
Discussion

25. Change for Definite Diagnosis
• Pure AKI: High Reversibility
However some develop CKD (? severity)
• AKI on CKD: Moderate Reversibility
Many pass to ESRD
• ESRD on Conservative: may change to dialysis requiring
• ESRD on CHDx: is usually a settlement diagnosis
Discussion
?? AKI → Renal Fibrosis

26. Starting urgent HDx session:
based mainly on
certain indications
To prevent life threatening
problems
Discussion

27. Therapeutic goals of RRT
Correct acidosis
Correct
hyperkalemia
Correct refractory
hypervolemia
Correct uremic
symptoms
Correct high serum
creatinine
Discussion

28. Importance of pre-dialysis care
• CKD Patients: unaware of their illness
• Absent care to check progression
• Come into Urgent Need of HDx without Preparation
Discussion

29. Preserving residual renal function;
 Preventing or treating complications of CKD;
 Ensuring that patients have sufficient understanding of their condition
to decide whether they wish to have dialysis or not and to choose
between PD and HD;
 Arranging appropriate access; and in appropriate patients,
 Preparing for kidney transplantation.
Discussion
Pre-dialysis care should address:

30. *Urgent hemodialysis is life-saving and a useful modality to
stabilize the patient.
*Inevitable death may be caused by non-renal causes.
*Improved kidney function could be achieved in most patients.
Conclusion

31. Recommendations
In CKD: The need of pre-dialysis care is extremely important
to avoid acute incidents that are considered life threatening
and prepare the vascular access for future dialysis.
In AKI: Early initiation of urgent hemodialysis is highly
recommended to avoid extreme metabolic derangements.