Dialysis induced cardiac and brain injury

Transcription

1 Dialysis induced cardiac and brain injury Dr Nick Selby Consultant Nephrologist, Royal Derby Hospital, UK

2 How can dialysis hurt patients? Wasting Inflammation Infection Cognitive loss, depression Increased dependency Accelerated end organ damage Heart Gut Brain Death

3 Pathophysiology of IDH

4 Effect of HD on global and segmental myocardial Blood Flow McIntyre CW, Burton JO, Selby NM et al. CJASN 2008 Jan;3(1):1

5 Detecting HD induced myocardial stunning: Regional Wall Motion Analysis Semi-automated software Wall motion is calculated over 10 regions and expressed as %SF RWMA is defined as reduction in SF of >20% between baseline and peak images More than 2 RWMAs are significant

6 Factors associated with the presence of RWMAs Factors associated with development of >2 RWMAs (r 2 =0.602) 43/70 (61%) Factor associated with development of myocardial stunning OR UF volume during HD of 1L 5.1 UF volume during HD of 1.5L 11.6 UF volume during HD of 2L 26.2 Max SBP reduction during HD of 10 mmhg 1.8 Max SBP reduction during HD of 20 mmhg 3.3 Max SBP reduction during HD of 30 mmhg 6.0 P value >2 RWMAs 2 RWMAs ctnt Age Burton JO, Jefferies HJ, Selby NM, McIntyre CW. CJASN 2009 May;4(5):

7 HD Induced Myocardial Stunning Leads to Myocardial Hibernation and increases Mortality Hibernation of segments co-localised with stress induced RWMAs Reduction in LVEF ~ 10% (absolute) At rest and at peak stress on HD Burton JO, Jefferies HJ, Selby NM, McIntyre CW. CJASN 2009 Dec;

8 Mean no. of unaffected LV regions per patient BP (mmhg) SF (MEAN) (%) Mean no. of unaffected LV regions per patient SF (MEAN) (%) BP (mmhg) Reduction in RWMA number and severity with dialysis modification HD a) standard dialysis vs. biofeedback * HD BFD ** * BFD HD BFD Baseline Peak Recovery 200 b) standard dialysis vs. cool dialysis 160 HD 37 HD Baseline Peak Recovery Time (min) HD 37 HD 35 HD 37 HD Baseline Peak Recovery 2.2 Baseline Peak Recovery Selby NM, Time Lambie S, Baker C, Camici PG, McIntyre CW. AJKD 2006 Selby NM, Burton JO, Chesterton LJ, McIntyre CW. Clin J Am Soc Nephrol 2006

9 weight (kg) SBP(mmHg) Daily dialysis impact on UF and BP Weight loss rate vs. Weight change Pre-dialysis to Peak Number stress of stunned Change segments in Systolic BP, Pre-dialysis to Peak stress D Wt pre-peak (mg/kg/hr) CHD3 CSD HSD -20 HN r=-0.409, p= Patients matched for age, sex, history of IHD and dialysis vintage CHD3 CSD HSD HN Jefferies HJ, Schiller B, Moran J, McIntyre CW. CJASN 2011

10 Effect of HD initiation on overall dependency Smoothed Trajectory of Functional Status before and after the Initiation of Dialysis and Cumulative Mortality Rate. Kurella Tamura M et al. N Engl J Med 2009;361:1539-

11 Impact of depression on outcomes Mortality risk Risk of first hospitalization Lopes AA et al. Kidney Int 2002

12 Cerebral circulation Generalised cerebral atrophy Increased in HD patients Silent Cerebral Infarcts HD patients >controls Leukoaraiosis More common in dialysis patients Endotoxin effects Defective autoregulation Immunoactivation Effects on cerebral blood flow

13 Effects of HD initiation - Brain MRI White matter fractional anisotropy maps

14 HD effects on brain anisotropy HD intiators Controls FA ± ± 0.04 MD ± ±

15 The Effects of Cooling the Dialysate on Systolic Dysfunction in Haemodialysis Patients A Multicentre Randomised Controlled Cross sectional Study Excluded: 1. exposure to haemodialysis for >90 days. 2. Contraindications for using MRI or inability to tolerate MRI 3. Unable to obtain echocardiographic data of sufficient quality to permit analysis. 4. Cardiac transplant recipients. 5. Severe LV systolic dysfunction (New York Heart association grade IV) Inclusion criteria: On HD at least 3 times/week Aged 16 years or over Randomization Cardiac MR Monitored Dialysis Investigations* Cool Dialysate Group 0 Months Control Group Monitored Dialysis Investigations* Cool Dialysate Group 6 months Control Group Cardiac MR Monitored Dialysis Investigations* Cool Dialysate Group Crossover 12 Months Control Group Cardiac MR Monitored Dialysis Investigations* Control Group to have cool Dialysate 18 months End of Study Cool Dialysate group to become control *Monitored Dialysis Investigations Comprise: Non-invasive heart function and peripheral blood vessel monitoring with Bioreactance and Viacorder, Echocardiography, 24Hr ECG, blood tests.

16 HD hurts hearts and brains - and a whole lot more besides ENDOTOXIN