Hemodialysis Emergencies: Core Curriculum 2021

Since maintenance hemodialysis (HD) first became available in the United States 1962, there has been tremendous growth population of patients with kidney failure. HD become a routine treatment carried out outpatient clinics, hospitals, nursing facilities, and patients’ homes. Although it is complex procedure, quite safe. Serious complications are uncommon due to use modern machines water systems as well development strict protocols monitor various aspects treatment. The practicing nephrologist must be knowledgeable about life-threatening that can occur during able recognize, manage, prevent them. This installment AJKD Core Curriculum Nephrology reviews pathogenesis, management, prevention 9 emergencies. emergencies covered include dialyzer reactions, dialysis disequilibrium syndrome, uremic/dialysis-associated pericarditis, air embolism, venous needle dislodgement, vascular access hemorrhage, hemolysis, contamination, arrhythmia episodes. FEATURE EDITOR:Asghar RastegarADVISORY BOARD:Ursula C. BrewsterMichael ChoiAnn O'HareManoocher SoleimaniThe aims give trainees nephrology strong knowledge base core topics specialty by providing an overview topic citing key references, including foundational literature led current clinical approaches. EDITOR: Asghar Rastegar ADVISORY BOARD: Ursula Brewster Michael Choi Ann O'Hare Manoocher Soleimani Hemodialysis life-sustaining for failure severe acute injury (AKI). In 1945, Dutch physician Willem Kolff successfully used his “artificial kidney” treat uremia patient AKI who went on have recovery her function. Maintenance 1962. For decade, was only select few its significant cost. Anonymous committees determined which met criteria receive HD; those were not selected died. 1973, Medicare End-Stage Renal Disease program established, ensuring nearly universal coverage transplantation States. then, increased beyond original projections, 470,000 more than 52,000 peritoneal at end 2017. Well over 50 million treatments performed each year. procedure It involves creation access; generation suitable making dialysate; circulation blood through extracorporeal circuit; administration medications such heparin, intravenous iron, erythropoiesis-stimulating agents, active vitamin D. Complications any these steps, range from mild life-threatening. Fortunately, serious uncommon, but some result human error and, such, should preventable. review covers their management. ?Gottschalk CW. History science dialysis. Am J Nephrol. 1997;17:289-298.?Anumudu SJ, Eknoyan G. A historical perspective how public policy shaped care delivery Semin Dial. 2020;33(1):5-9.?Saran R, Robinson B, Abbott KC, et al. US renal data system 2019 annual report: epidemiology disease Kidney Dis. 2020;75(1)(suppl 1):S1-S64.?Golper TA, Fissell WH, Hemodialysis: curriculum 2014. 2014;63(1):153-63. ?ESSENTIAL READING Case 1: 68-year-old woman hypertension, diabetes, chronic (CKD) stage 5 initiated volume overload refractory diuretic agents. Ten minutes into treatment, she reports generalized pruritus, dyspnea, chest pain. She noted audible wheezing. Her pressure 86/50 mm Hg (compared 145/90 prior start dialysis). reaction suspected.Question What appropriate next steps management this patient?a)Continue administer antibioticsb)Continue albuterol nebulizerc)Continue corticosteroids antihistaminesd)Stop return circuit back patiente)Stop without returning patientFor answer question, see following text. suspected. Question composed many hollow fibers made biocompatible membrane across solutes cleared diffusion convection. Dialyzer reactions hypersensitivity itself or products sterilize membrane. Reactions reported dialyzers cuprophane, cellulose commonly past; acrylonitrile, synthetic caused among taking angiotensin-converting enzyme inhibitors (ACEIs); polysulfones polyethersulfones, most membranes. Insufficient rinsing after ethylene oxide, membranes past, formaldehyde, reprocess dialyzers, being exposed substances. previously called “first use” because they typically seen when time reused (dialyzer reuse today States). once fairly common, now rarely reduced oxide sterilization. characterized type B. Type early usually within 20 30 minutes. They multiple treatments. Signs symptoms may urticaria, laryngeal edema, bronchospasm, pain, vomiting, hypoxia, hypotension, cardiac arrest. Management includes stopping patient; thus, correct 1 (e). Fluids, epinephrine, corticosteroids, antihistamines administered indicated. future treatments, different method sterilization (eg, switching steam- oxide–sterilized gamma ray–sterilized dialyzer). Use ACEIs acrylonitrile 69 (AN69) avoided. B later less severe. Symptoms nausea, vomiting. Dialysis continued if mild, although considered. mechanism varies depending causative agent. Most attributed accounting reactions. Ethylene formaldehyde cause true, immunoglobulin E (IgE)-mediated anaphylaxis. AN69 appear stimulate bradykinin production. When coupled ACEIs, inhibit degradation bradykinin, very high plasma levels occur. prevented pretreated polyethyleneimine, positively charged polymer binds negatively Cuprophane polysulfones/polyethersulfones activate complement, thought main However, elevated IgE polysulfone dialyzers. Measuring total tryptase (a protease released mast cells anaphylaxis) helpful determining whether complication occurring anaphylaxis other cause. Hypersensitivity also dialysis, agents (ESAs). subset heparin-induced thrombocytopenia develop anaphylactoid immediately heparin re-exposure mediated IgG antibodies. 2007-2008, clusters undergoing traced lots contaminated oversulfated chondroitin sulfate (OSCS). OSCS found generate anaphylatoxins C3a C5a. Intravenous iron long associated precise underlying unknown. rate fatal adverse formulation, rates high-molecular-weight dextran lowest sucrose, currently formulation. There cases ESAs additives. all cases, avoidance offending agent substitutes where available. ?Boer Liem Y, de Beus E, Abrahams AC. Acute polysulfone/polyethersulfone dialysers: Neth Med. 2017;75(1):4-13.?Butani L, Calogiuri receiving hemodialysis. Allergy Asthma Immunol. 2017;118(6):680-684.?Saha M, Allon M. Diagnosis, Clin Soc 2017;12(2):357-369. READING?Sayeed K, Murdakes C, Spec A, Gashti Anaphylactic shock beginning 2016;29(1):81-84.?Kishimoto TK, Viswanathan Ganguly T, Contaminated events activation contact system. N Engl 2008;358:2457-2467. 2: 75-year-old man CKD, history ischemic stroke decreased appetite, hyperkalemia. His predialysis laboratory values notable serum creatinine (Scr), 10.1 mg/dL; urea nitrogen, 170 sodium, 128 mEq/L; potassium, 7.2 bicarbonate, 12 glucose, 101 mg/dL. prescription calls duration 2 hours, flow 400 mL/min, dialysate 800 standard sodium dialysate, target ultrafiltration liters. low-efficiency used. uneventful until he new onset headache. 145/96 Hg, stable throughout He subsequently develops seizure. stopped immediately.Question How could modified reduce risk syndrome?a)Reduce goalb)Reduce concentrationc)Reduce flowd)Increase timeFor immediately. syndrome (DDS) neurologic signs shortly session. First described 1960s, manifestations headache, nausea/vomiting, confusion, agitation, seizures, coma, even death. Cerebral edema computed tomography (CT) magnetic resonance imaging (MRI). DDS significantly nitrogen (SUN) Other factors rapid reduction SUN, extremes age, metabolic acidosis, hyponatremia/hypernatremia, liver disease, pre-existing conditions. incidence believed declined recent decades changing practices starting lower SUN levels. rare, possible underrecognized exhibit milder symptoms. cerebral movement brain (Fig 1). prevalent theory postulated explain occurrence “reverse effect.” states lowers osmolality relative central nervous (CNS), generating osmotic gradient drives cells. fact, measurement cerebrospinal fluid (CSF) 1960s showed higher CSF Increased expression aquaporins AQP4 AQP9 transporter UT-B1 observed uremic rats, suggesting increase movement. Idiogenic osmoles intracerebral acidosis proposed mechanisms. unidentified generated under hyperosmolar conditions hyperglycemia hypernatremia. idiogenic study dogs appeared show animals accounted chloride, alone. subsequent studies provided further evidence support theory. correction role increasing worsening acidosis. animals, decrease pH hydrogen ions displace bound potassium ions, osmolality. Beyond CNS osmolality, uptake opioids, causing changes mental status mimic severely acidemic initiating HD. depends severity If concerning stopped. Mild managed supportively. symptoms, measures intracranial Administration hypertonic saline mannitol hyperventilation published outcomes poor. Prevention reducing no 40% short period crucial. Initiating using low 200 mL/min hours (or patient’s body habitus) recommended; therefore, (c). patients, so recommended. slower continuous replacement therapy (CKRT) considered, case CKRT. Another approach degree change DDS. mannitol, glycerol, urea. ?Zepeda-Orozco D, Quigley R. syndrome. Pediatr 2012;27(12):2205-2011. READING?Mistry K. Int Nephrol Renovasc 2019;12:69-77.?Kennedy AC, Linton AL, Eaton JC. Urea haemodialysis. Lancet. 1962;1(7226):410-1.?Dalia Tuffaha AM. leading sudden death patient. Hemodial Int. 2018;22(3):E39-E44.?Tuchman S, Khademian ZP, Mistry therapy. J. 2013;6(5):526-9. 1836, English Richard Bright presence pericarditis autopsy. Prior diagnosis setting CKD heralded impending More recently, classified (defined developing before 8 weeks initiation dialysis) dialysis-associated exact Uremic accumulation toxins, improves initiation. Dialysis-associated frequently occurs inadequate intensified dialysis; unclear entity distinct pericarditis. Some experts suggested viral illness stress trigger disease. With earlier efficient machines, much common past. remain causes pericardial infections, autoimmune malignancy, trauma, myocardial infarction. Chronic inflammation constrictive presentation differ Pleuritic pain improvement leaning forward reported. Uremic/dialysis-associated accompanied fever, chills, cough, malaise. friction rub heard patients. triphasic components corresponding atrial systole, ventricular filling diastole. On electrocardiography, diffuse ST-segment elevations classically nondialysis 10% patients; prevalence left hypertrophy others indicate lack epicardial involvement. An echocardiogram evaluate effusion tamponade. Laboratory erythrocyte sedimentation C-reactive protein; leukocytosis approximately 50% cases. Pericardial exudative, mononuclear seen. Cardiac tamponade 10%-20% Patients present tachycardia, muffled heart sounds, jugular pressure. Pulsus paradoxus, defined inspiratory systolic 10 normal breathing, suggestive lead urgent evaluation. collapse right atrium ventricle diastole variation tricuspid mitral valve velocity respiration. latter inspiration, drop pleural reduces pressure, increases return, valve, volume. (referred interdependence) diastolic valve. requires pericardiocentesis avoid cardiogenic already These respond require intervention. Intensification recommended daily 10-14 days. do improve intensification fewer study, 87% improved whereas 53% responded intensification. Avoiding concern hemorrhagic Fluid removal attempted cautiously precipitate Medications indomethacin, colchicine, oral intrapericardial evaluated small benefit. Significant effusions Treatment options drain placement window. drain, monitoring reaccumulation required. complete pericardiectomy. ?Dad Sarnak MJ. Pericarditis end-stage 2016;29(5):366-73. READING?Khan I, McCreery Images medicine. 2013;369(13):e17.?Rehman KA, Betancor J, Xu effusion, disease: Insights pathophysiology. Cardiol. 2017;40(10):839-846.?Sadjadi SA, Mashahdian A. pericarditis: report literature. Rep. 2015;16:169-173.?Vijani P, Cherian SV, Gajjala Reddy N, Estrada-Y-Martin RM. decompensation effusion. Thorac Soc. 2018;15(5):633-636. 3: 70-year-old starts nontunneled catheter coronary artery bypass surgery. suddenly hypotension. examination reveals murmur systole diastole.Question step addition HD?a)Place 100% oxygenb)Start thrombolytic therapyc)Start antihistaminesd)Obtain echocardiograme)Place reverse Trendelenburg positionFor position Air embolism potential every entry bloodstream. pulled arterial portion (from pump) negative connection between poor defects tubing. Improper medications, priming dialyzer, introduction circuit. enters mechanisms; however, detected air-foam detector. entering trap level, sensor triggers alarm stops pump. resumed assessing line then necessary remove Because safety mechanism, rare. Cases years clamp tubing catheter, error. depend organ(s) affected. Very bubbles, termed microbubbles microemboli, detector enter immediate effects responsible lungs amount pulmonary systemic patent foramen ovale, large circulation; cannot eliminated capillaries, ends up circulation. Once circulation, emboli occlude vessels injury. arteries involved, altered status, deficits, strokes, CT MRI. ascending internal vein cortical veins cavernous sinuses seated adult, 100-300 mL likely lethal. supplemental oxygen hypoxia size removal; therefore (a) 3. Fluids vasopressors needed. suspected known