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First few session care

First few session care. PANTIPA TONSAWAN, M.D. July 5, 2013 . Scope.  Relation : ESRD , HD & death .  Pre HD patient evaluation .  HD prescription ( initial treatment ).  HD complication ( Initial treatment ). Impact : ESRD,HD & death .

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First few session care

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  1. First few session care PANTIPA TONSAWAN, M.D. July 5, 2013

  2. Scope Relation : ESRD , HD & death Pre HD patient evaluation  HD prescription (initial treatment)  HD complication (Initial treatment)

  3. Impact : ESRD,HD & death

  4. Probability of sudden cardiac death in incident dialysis patients Probability Month after dialysis U.S. Renal Data System, USRDS 2012 Annual Data Report

  5. Causes of death : prevalent dialysis patients, 2008–2010 ESRD pt Cardiac causes U.S. Renal Data System, USRDS 2012 Annual Data Report

  6. Rates of sudden cardiac death : age Period prevalent dialysis patients, age 20 & older, unadjusted. U.S. Renal Data System, USRDS 2012 Annual Data Report

  7. Rates of sudden cardiac death prevalent dialysis patients, by primary diagnosis Death /1000 patient years 2000 2005 2010 U.S. Renal Data System, USRDS 2012 Annual Data Report

  8. Rates of sudden cardiac death following initiation of treatment in incident HD patients 0-90 days : 1/10 Death /1000 patient years 2000 2006 2007 2007 2009 U.S. Renal Data System, USRDS 2012 Annual Data Report

  9. Caution !!! : sudden cardiac death  RRT :Hemodialysis Aging : Exp > 65 yrs…>75 yrs  Underlying : DM, HT  Duration initial treatment : 0-90 days

  10. Patient evaluation

  11. Pre HD Evaluation Vascular access Hemodialysis prescription Patient information

  12. Patient information 1.History taking  Indication & complication Acute or chronic HD, hyper K, volume↑  Underlying disease…DM, HT, IHD  Active problem ..GI Bleed, MI, stroke Hemodynamic status  Arrhythmia, BP Medication  Anti HT, anti coagulant

  13. Patient information 2.Laboratory data  CBC :  Hb/HCT, Platelet…..risk bleeding  BUN/Cr : High BUN…..Risk ….DDS  Electrolyte : Select : Dialysate solution component Serology:  HBV, HCV, HIV…..isolated

  14. Vascular access : initial use Arteriovenousfislula Prepare : 3-6 mo ….. Maturation Prompt ? Arteriovenous graft Prepare : 3-6 wk : at least 2 wk after Surgery Infection ? HD catheter Exit site, redness, warm immediately use ..complication ?

  15. Hemodialysis prescription

  16. Order HD prescription (initial treatment) • Session length : Perform HD 2 hrs • BFR: 200 ml/min • Dialyzer: Low flux • Dialysatesolution composition: • Na …, K…., HCO3 …, Ca…, Mg…, Dextrose….. • DFR: 500 ml/min • Dialysis solution temp.: 36oc • Fluid removal order: remove … Lite • Anti-coagulant : heparinloading..,maintenance … (หรือnon-heparin ตามความเหมาะสม) • 50 % glucose 50-100 ml intra HD (พิจารณาตามความเหมาะสมของผู้ป่วยแต่ละราย) Daugirdas JT. Acute & Chronic hemodialysisprescription; Handbook of dialysis 2007

  17. HD prescription (initial treatment) Time: initial 2 hr… ↑ 30 min q HD ……until 4 hr BFR : initial 200-250 ml/min …↑ 30 min q HD ……until 350-400 ml/min Dialyzer: initial low flux, low SA …. (AIM ….Kt/V 0.6-0.7, URR 40 %) DFR : 500 ml/min …800ml/min (high BFR) Daugirdas JT. Acute & Chronic hemodialysisprescription; Handbook of dialysis 2007

  18. HD prescription (initial treatment) Dialysate composition : Temp. : low temp prevent Hypotension 36.5 C  UF : < 1 L /hr, ….if need…sequential HD  Hypertonic solution : 50 % glucose ….DDS Anticoagulant : depend on patient. condition Daugirdas JT. Acute & Chronic hemodialysisprescription; Handbook of dialysis 2007

  19. Hemodialysis complications

  20. Dialysis disequilibrium syndrome Acute neurological complication Consequence of rapid HD …osmotic gradient brain Vs plasma caused .. cerebral edema Risk factor 1st session hemodialysis  Extreme age : child or aging  High BUN level: > 125 mg/dl  CNS disorder (stroke, tumor, dementia,hypoNa), head injury (subdural hematoma) …. PediatrNephrol (2012) 27:2205–2211 Seminars in Dialysis—Vol 20, No 3 2008 pp. 493–498

  21. Dialysis disequilibrium syndrome ICF ECF IVF I Urea CF : brain ICF : brain Brain Urea Urea H2O Urea↑ High Osm Urea H20 slow Reverse osmotic shift HD Cerebral edema

  22. Dialysis disequilibrium syndrome Clinical : fatigue, mild headache, nausea, vomiting, disturbed consciousness, convulsions… coma. Common mild..Self limited, fatal.. if severe Diagnosis Clinical diagnosis (during HD, after HD) + riskfactorExclusion other condition Treatment Symptomatic treatment/ hypertonic solution/ + stop HD Seminars in Dialysis—Vol 20, No 3 2008 pp. 493–498

  23. Dialysis disequilibrium syndrome Prevention Most important Dialysis time (2 hours) Blood flow rate 200 ml/min  Less efficient (small) dialyzer  Hypertonic solution  A goal URR : 0.4–0.45 or diffusive Kt/V of 0.6–0.7 Seminars in Dialysis—Vol 20, No 3 2008 pp. 493–498

  24. Cardiac arrhythmia, Ischemia, sudden death DIALYSIS-INDUCED MYOCARDIAL STUNNING • Echocardiogram • -Pre HD …normal • - During HD …. RWMA abnormality • - Post HD 30 min …normal Semin Dial 2007; 20: 220–228  Positron emission tomography: Measure ..MBF dialysis ….. HD precipitates reductions MBF CAG …..normal Clin J Am Soc Nephrol 2008; 3: 19–26. ;Kidney International (2009) 76, 371–375 Effects of hemodialysis on cardiac function

  25. Cardiac arrhythmia, Ischemia, sudden death DIALYSIS-INDUCED CARDIAC ISCHEMIA Myocardial stunning : Occur ….60 % Related to UF (total/rate ) & HD instability Long term High mortality PET ;Kidney International (2009) 76, 371–375 Effects of hemodialysis on cardiac function

  26. Intradialytic hypotension Initial treatment : associated cause High UF rate : limit time Trial & error : set DW High dose : anti HT Nutrition status : malnutrition …low plasma refilling Treatment  Sequential HD Limit IDWG < 1 kg/day  Decrease anti HT ….decrease DW  Avoid : eating during HD low Temp.

  27. Type A : anaphylactic type Dialyzer reaction • Type B :non-specific  Full brown, Severe reaction  Common : 5 min after HD…but delayed 30 min  Cause : ETO oxide, AN 69 reaction, contaminated dialysis solution, reuse First use syndrome Management : Safest to stop dailysis, without returning blood  Cardiorespiratory support Prevention : proper rinsing, y-irradiated or stream-sterilized dialyzer

  28. Dialyzer reaction Type B :non-specific  Mild symptoms : chest pain, back pain  Onset 20-30 min after HD  Cause : unknown Management :  Supportive care  Differential diagnosis : coronary artery disease

  29. Post HD care Complication Next session HD

  30. Summary  Cardiovascular : common cause of death HD patient  Risk :aging, DM, HT, HD 0-90 day  Pre HD patient evaluation: important …Recognized risk of HD complication  Appropriate HD prescription …reduce & prevent HD complication Prompt to treatment of complication : if HD… started

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