Causes of Intradialytic hypotension(idh)

Transcription

1 fluid management

2 Causes of Intradialytic hypotension(idh) Excessive fluid removal Ultrafiltration rate > 0.35 ml/min/kg Patient-related factors Autonomic neuropathy (e.g. DM, Uremia) Antihypertensive medications Sympathetic failure RAS and arginine-vasopressin syst. sensitivity Food ingestion(splanchnic vasodilation) Tissue ischemia(adenosine mediated) Bacterial sepsis Impaired Intradialytic venous pooling Vasoconstriction. Core body temp.anemia Decrease in plasma vol. > 20% Reduced plasma refilling rate Reduced ECV Hemorrhage Intradialytic Hypotension Dialysis-related factors Heart problems Myocardial Infarction.Structural heart dis Arrythmias Pericardial tamponade Hemolysis Dialyzer Rxn Air embolism Acetate dalysate (adenosine-mediated).low dialysate Na &/or ionized Ca conc Complemant activation (C3a and C5a-mediated) Cytokine generation(il-1 and NO-mediated)

3 Water movement during standard hemodialysis Intracellular fluid Extracellular fluid Dialyzer step3 Water movement Osmolality Osmolality mosm/kg mosm/kg Osmolality mosm/kg 320 Falling to 290mosm/ kg as diffusion occurs Compensatory refilling step1 280 step2 Loss of urea and water

4 Fluid removal Plasma refilling

5 Fluid removal Fluid removal Na Low Na meq/l Na Increased risk of hypotension

6 urea removed by dialyzer urea sequestration in tissue fluid Effluent Dialysate Increased intracellular osmolarity Inffluent Dialysate fluid Na

7 Fluid removal Plasma refilling Na Na >145 meq/l Na

8 Pathophysiological Changes Induced by Low and High Dialysate Change Low Na+ Dialysate High Na+ Dialysate Decrease in ECF Osmolality Increase in ECF Osmolality H20 from EC to IC Increased Renin & Aldosterone Decreased ECV/ Increased ICV H20 from IC to EC Decreased Renin & Aldosterone Increased ECV/ Decreased ICV

9 Intradialytic hypotension (IDH):.definition Decrease in SBP 20 mm Hg or MAP < 10 mm Hg, associated with clinical events and need for nursing. intervention Intervention may be IV saline administration,.trendelenburg position Asymptomatic SBP <90 mm Hg should be.considered as hypotension 1, EBPG, NDT , K/DOQI Am J Kidney Dis. 2005

10 .Complications of recurrent IDH Reduced efficiency of dialysis. Compartmentalization leading to sequestration of uremic toxins. Reduced time on dialysis. Organ ischemia. Brain: cerebro-vascular events. Gut: ischemia, gram negative sepsis.

11 Salt & volume overload Vascular Space Interstitial Space Cardiac Output SNS activity Renin angiotensin activity Blood Pressure Inappropriate Vascular resistance

12 Clinical Significance In 17% of all treatments, intradialytic hypotension seen. 25% are free of intradialytic hypotension 75% of all patients has had at least 1 episode. 16% of all patients had more than 1x/week on average. These patients had higher mortality rate, higher admission rates and longer hospital stays. Dialysis facility was an independent predictor. Older patients Longer dialysis vintage Diabetes Lowe pre-dialysis blood pressure Higher Uf goal In essence, the BP depends on: 1) Cardiac reserve 2) Intravascular volume and Uf rate 3) Vascular tone In a study of 1137 patients over 44,801 treatments among 13 outpatient dialysis facilities. Sands, J. et al. 2014, Intradialytic hypotension: Frequency, sources of variation and correlation with clinical outcome. Hemodialysis International, 18:

13 Patients at risk of IDH 65 years or older age DM Patients with CVD: LVH and diastolic dysfunction with or without CHF LV systolic dysfunction and CHF Valvular heart disease Pericardial disease (constrictive pericarditis or pericardial effusion) Poor nutritional status and hypoalbuminemia Hyperphosphatemia Uremic neuropathy or autonomic dysfunction due to other causes Severe anemia Patients requiring high volume ultrafiltration; more than expected interdialytic weight gain Patients with predialysis SBP of <100 mm Hg

14 HYPOTENSION AVOIDANCE Hemodialysis-induced Cardiac Dysfunction Is Associated with an Acute.Reduction in Global and Segmental Myocardial Blood Flow Ref: Christopher W.Mclntyre james o.burton Nicholas M. Selby, Lucia leccisolti Shvan korsheed, Christopher S.R Beker and Paolo G. camici Hemodialysis-Induced Repetitive Myocardial Injury Results in Global and Segmental Reduction in Systolic Cardiac Function. Ref: JAMES O.BURTON, HELEN J.JEFFERIES,NICHOLAS M.SELBY, AND CHRISTOPHER W. MCINTYPE,CHIN J SEC NEPHRED ,2009

15 EBPG guideline on haemodynamic instability o o o o o o o First-line approach Second-line Third-line approach approach DietaryoTry counselling (sodium to assess objective methods (only if other restriction). dry weight. Refraining fromcardiac foodtreatment intake operform evaluation. options duringodialysis. failed) Gradual reductionhave of dialysate Clinicaltemperature reassessment dry fromof 36.5 C weight.downward (lowest oconsider 35 C) midodrine. or Use of isothermic bicarbonate as oconsider treatment (possible l-carnitine dialysis buffer. supplementation. alternative: convective oconsider peritoneal dialysis. Use of treatments). a dialysate oconsider temperature of 36.5 C. individualized blood Check volume dosing controlled and timing of feedback. oprolong dialysis antihypertensive agents time and/or increase dialysis frequency. oprescribe a dialysate calcium concentration of 1.50 mmol/l. Kooman J, Basci A et al. Nephrol Dial Transplant May;22 Suppl 2:ii22-44.

16 Dialysate Temperature Vasoconstriction to maintain BP Vasodilation to lower temperature Raises the body core temperature Drops the BP A reduction in dialysate temperature from 36.7 to 34.4 decreased the frequency of IDH from 0.58 to 0.05 episodes per treatment in a study of 7 patients with frequent IDH. (Sherman, 1985) Temperature setting of at least 1 degree from the actual body temperature seem to help. Multiple similar study results in the efficacy of lower dialysate temp.

17 Principles of fluid management practice Retained fluid & salt Goal Vascular stability Remove fluid without adverse events Prevent Long term CVDShort term hypotension- BTMDialysate temp- PRR UFR<12.4 ml/kg/hruf profilesdt frequency- Avoid Saline- Monitoring BP (frequency)cardiac (Apex)- Target Weight :(IDWT) Fluid assessment1/12 BCM 1/12- f: Fresenius MEA Nephrology Academy and EDTNA 2017 Evaluate

18 Body Composition Monitoring- BCM :BCM assists in the assessment of the following clinical parameters Monthly review (pre-dialysis) Quantification of fluid status Over hydration Total body water(v) Assessment of body composition Lean tissue mass Adipose tissue mass Ref: Fresenius MEA Nephrology Academy and EDTNA 217

19 ?Why all the Physiology Stuff Gain of water (5% Dextrose) 5% Dex 1L 5% dextrose infused into the intravascular compartment (ECF) will redistribute throughout the whole body water space of which only 3.5L is intravascular space. Therefore you would need to infuse 13l of 5% dextrose to increase the plasma volume by 1L Plasma ICF Interstitial

20 ?Why all the Physiology Stuff Gain of water & electrolytes eg 0.9% NaCl Na+ & Cl- at concentration of 150 mmol/l Osmolality matches that inside the cells therefore no net change in the osmolality and no net movement of water.into the cells so fluid remains in the extracellular space 0.9% NaCl Plasma ICF Interstitial

21 Why all the Physiology Stuff? - Pop Quiz IV infusion of Colloids (solutions containing high molecular weight molcules/proteins eg Gel fusion) Where does it go? A) Intravascular/Plasma space Gelofusion Plasma ICF Interstitial

22 Why all the Physiology Stuff? - Pop Quiz IV infusion of Colloids (solutions containing high molecular weight molcules/proteins eg Gelofusion) Where does it go? B) Draws fluid in (plasma. expander) Gelofusion Plasma ICF Interstitial

23 Factores affecting Plasma refilling PR Measures to reduce risk Blood Volume PR UF PR Ref: Fresenius MEA Nephrology Academy and EDTNA 2017 Reduce IDWG decrease UFR Prolong dialysis time decrease UFR Increase dialysis frequency decrease UFR Limb exercise Increase PRR Ultrafiltration profiling Increase PRR Balance PRR and UFR Avoid saline boluses Increase PRR

24 Summary Safe Uf rate is <12.4 ml/kg/hr. Remind patients to drink less liquids. Discuss with the patient/physician to increase dialysis time. Low dialysate temperature in place? Monitor for changes in MAP. Pre-emptive holding of Uf for 10 minutes until MAP better? Saline, hypertonic saline, 20% dextrose, albumin as per local procedures and physician orders. Na profiling: Pros vs. Cons Uf profile review Holding BP medications pre-dialysis Discuss with physicians re: midodrine, caffeine, Zoloft Role of Blood Volume Monitoring? Always think of acute issues Is Peritoneal Dialysis an option?

25 THANKS FOR YOUR ATTENTION

26 Different patterns of sodium modeling meq/lit Na concentration meq/lit Hours after dialysis initiation

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30 Goals of UF Profiling Provide adequate ultrafiltration (UF) Minimize symptoms related to hypovolemia Enhance plasma refill Allow the patient to reach estimated dry weight (EDW) Plasma refill: Refilling of the blood compartment, or vascular space from the surrounding tissue spaces Hypovolemia: Decreased blood volume leads to decreased cardiac output which can cause hypotension

31 Profiling Ultrafiltration: Allows the patient to reach their estimated dry weight (EDW) Helps prevent symptoms Allows refilling of vascular fluid volume from the interstitial space (plasma refill) Allows higher volume fluid removal at times when fluid is more readily available Prevents hypotension 31

32 A patient weight gains typically of 3-4 kg and experiences moderate to severe leg cramps during the last 30 minutes of treatment 32

33 Patient tolerates fluid removal (higher UF) at the beginning of treatment Systolic BP Symptoms are relieved at the end of treatment with a lower UF UF Profile Time in Minutes 33

34 220 Systolic BP Fluid overloaded 200 patients benefit from 180 aggressive UF at 1.8 Kg/h 160 the beginning of the treatment Step profiles allow for 80 dramatic decreases in UF. 60 Lower UF at the 40 middle and end of treatment will reduce the patient s symptoms UF Profile Time in Minutes 34

35 Second patient arrives with a systolic blood pressure of 85 and a weight gain of 3 Kg. If her SBP falls below 75 she becomes symptomatic 35

36 220 Less UF should be used at the beginning of 200while the SBP treatment is low. 180 Increase the UF during periods when the SBP 160is higher Systolic BP Decrease the UF toward the end of treatment as the patient approaches her dry weight to prevent symptoms Time in Minutes 36

37 220 Using a Step Profile, you can create multiple minimum UF periods which will allow plasma refill to occur. Decrease the UF toward the end of treatment as the patient approaches her dry weight to prevent symptoms Systolic BP Time in Minutes 37

38 A woman patient is hypertensive and diabetic. She has large fluid gains of 4-6 Kg between treatments and has symptoms of hypotension about 45 minutes into the treatment as well as mid and late treatment 38

39 Assessment and Plan Assessment: Large fluid gains Severe hypotensive episodes Poor plasma refill Plan Support plasma refill, especially during the first part of the treatment Prevent hypovolemia Consider conductivity profiling in addition to UF profiling 39

40 Utilize a Conductivity profile to support solute removal Systolic BP Arrows indicate plasma refill times Time in Minutes 40

41 220 UF and Conductivity Profiling can be used simultaneously with similar step curves 200 Systolic BP Time in Minutes 41

42 Systolic BP UF and Conductivity Profiling 100 can be used simultaneously with 80 similar progressive curves Time in Minutes 42

43 Clinical case study Name: Nasser Tabkhi Unit: Smarrt company Topic: Patient with Intradialytic episodic Hypotension

44 contents Background Laboratory Test Clinical problems Management outcome

45 Background A man with 68 years old, on hemodialysis since 2011 diabetic nephropathy hypertension vascular disease LVH diabetic retinopathy lungs were not clear to auscultation cardiac rhythm was regular Dialysis duration= 4 hours The single pool Kt/V on this man was 1.21 his dry weight was 82.5 kg average interdialytic weight gain was 5 kg per treatment

46 LABORATORY TEST BUN = 45 (mg/dl) cr = 9 (mg/dl) Hemoglobin= 11.5 g/dl Albumin = 3.4 g/dl Calcium = 8.9 mg/dl Phosphor = 6.5 mg/dl PTH = 558 pg/ml KT/V= 1.2

47 CLINICAL PROBLEM Large fluid gains Severe hypotensive episodes Poor plasma refill between treatments he had symptoms of hypotension about 45 minutes into the treatment as well as mid and late treatment At the beginning of dialysis session his BP= 160/74 after half an hour BP= 105/60 after one hour BP = 95/6 then BP decreased to 85/42

48 management Plan A Saline was administered Ultrafiltration was stopped Trendelenburg position Cool dialysate solution Dry weight was adjusted Counseling with nutritionist on limiting salt intake but they were not effective and Despite this intervention after starting uf again, the patient developed another episode of IDH Plan B Support plasma refill, during of the treatment Consider UF profiling and if necessary in addition to sodium profiling

49 Outcome to prevent episodic hypotension: By using Step UF and Sodium modeling(increasing osmolality of extra cellular space ) we create multiple minimum UF periods which will allow plasma refilling. Considering patient s cardiovascular and diabetes disorders and problems related to plasma refilling patient s BP has been stabled around 130/60 mmhg

50 Na profile Uf profile 220 Using a Step Profile, you can create multiple minimum UF periods which will allow plasma refill to occur. Decrease the UF toward during of treatment as the patient approaches her dry weight to prevent symptoms Systolic BP Time in Minutes

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52 Subclinical Negative Impact Brain Ischemia: MRI have shown pathologic changes with dialysis, worse with intradialytic hypotension (IDH) Brain white matter ischemic injury from loss of axons and myelin (McIntyre, Seminars in Dialysis, 2010) Cardiac Stunning: Echo during dialysis confirms the presence of LV regional wall motion abnormality (Chesterton, Hemodialysis International, 2010) Episodic IDH is thought to exacerbate evolving myocardial injury. Cardiac muscles receive coronary flow during diastole and most HD patients have a widened pulse pressure. Gut Stunning: Non-occlusive mesenteric ischemia is associated with frequent IDH. (Daugirdas, AJKD, 2001). Mesenteric ischemia may also allow bacterial endotoxins to be introduced into the circulation, causing vasodilation and reduced cardiac contractility. (McIntyre, Seminars in Dialysis, 2010)

53 References Heinrich, W.L. & Victor, R.G., Autonomic Neuropathy and Hemodynamic Stability in End-Stage Renal Disease Patients, Principles and Practice in Dialysis, Williams and Wilkins, Baltimore, Wilson, S., Alvarez, D., A Primer on Ultrafiltration Profiling and Sodium Modeling for Dialysis Patients, Contemporary Dialysis and Nephrology, April 2000, pp Bonomini, V., Coli, L., Scolari, M.P., Profiling Dialysis: A New Approach to Dialysis Intolerance, Nephron 1997; 75:1-6 Leunissen, K.M.L., Kooman, J.P., van der Sande, F.M., van Kuijk, W.H.M., Hypotension and Ultrafiltration Physiology in Dialysis, Blood Purif 2000; 18: Oliver, M.J., Edwards, L.J., Churchill, Impact of Sodium and Ultrafiltration Profiling on Hemodialysis Related Symptoms, J Am Soc Nephrol 12: Jensen, B.M., Dobbe, S. A., Squillace, D.P., McCarthy, J.T., (April 1994) Clinical Benefits of High and Variable Sodium Concentration Dialysate in Hemodialysis Patients, ANNA Journal, Vol. 21, No

54 References Gambro Basics 1 Gambro Education 1994 Petitclerc, T. and Jacobs, C. Dialysis sodium concentration: what is optimal and can it be individualized?, Nephrol Dial Transplant Editorial Comments1995, Coli, L., Ursino, M., Dalmastri, V., Volpe, F., LaManna, G., Avanzolini, G., Stefoni, S., Bonomini, V., A simple mathematical model applied to selection of the sodium profile during profiled haemdialysis, Nephrol Dial Transplant (1998) 13: Donauer,J., Kolblin, D., Bek, M., Krause, A., Bohler, J., Ultrafiltration Profiling and Measurement of Reletive Blood Volume as Strategies to Reduce Hemodialysis-Related Side Effects, AJKD, Vol 36, No 1 (July), 2000:pp Stiller, S., Bonnie-Schorn, E., Grassmann, A., Uhlenbusch-Korwer, Mann, A Critical Review of Sodium Profiling for Hemodialysis, Seminars in Dialysis, Vol 14, No 5 (September-October) 2001 pp Locatelli, F., DiFilippo, S., Manzoni, C., Corti, M., Andrulli, S., Pontoriero, G., Monitoring sodium removal and delivered dialysis by conductivity, The International Journal of Artificial Organs/Vol. 18/no. 11, 1995/pp

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