Q.546. Can you please summarize the efficacy of these various measures and recent guide lines?

 HEMODIALYSIS

Q.546. Can you please summarize the efficacy of these various measures and recent guide lines?

A. Comparative efficacy: The foll. results were rep. in a comparative studies:

{High sodium Dzt, sodium modeling & cool temperature DX.}⮞ Significant fewer hypotensive events . Compared to other strategies, sequential UF & isovolemic DX hd a signif. greater No. of hypotensive episodes . Post-DX upright B.P. was best é sod. modeling & cool ºC DX, comp. to standard & isolated UF DX. The best tolerated & most effective strategy⮞👆 Sodium modeling. High sod. & cool ºC DX were also effective, while sequential UF & isovol. DX ⮞less useful.

Guidelines: Resistant intradialytic hypotension (K/DOQI 2005 guidelines):

1)   Midodrine & Dzt ºC profiling.

2)   Dzt ºC profiling + 3 meq/L Dzt  Ca+.

3)   Dzt ºC & sodium modeling.

4)   Isolated UF & other approaches may provide benefit.

The 2007 European best practice guidelines in HDX. recommend:     👍

First-line: dietary counseling (sod.🠉), no food intake dur. DX, revise DW, HCo3 as DX buffer, Dzt ºC of 36.5ºC, and/or adj. dosing/timing of anti-H.T. drugs.

Second-line: objective methods to assess DW., cardiac clearance, gradual 🠟Dzt ºC fr. 36.5ºC (lowest 35ºC) or isothermic ttt (alternative is convective ttt), blood volume controlled feedback, 🠉DX time/frequency, and/or Dzt Ca+: 1.50 mmol/L.

Third-line: consider [midodrine, L-carnitine  or P.D.].

“Recommendations” for prevention:  👉

1)   Exclude non-DX related causes, e.g. [myocardial ischemia & pericardial effusion].

2)   Efforts shd be made to 🠟interdialytic wt. gain.

3)   DX prescription shd be thoroughly individualized :

                     I.        Accurate setting of the dry wt.

                   II.        Consider cooler ºC DX.

                 III.        Bicarbonate buffer.

                  IV.        Fixed sodium conc.>140 meq/L or sod. modeling

                    V.        Avoid low Mg & low Ca+ Dzt.

4)   Optimize UF: modeling alone or+Na modeling or sequential UF & isovol. DX.

5)   Avoidance of food & anti-H.T. drugs on DX day.

6)   Administration of midodrine.

Q547. What are the predictors👓of sudden cardiac death among hemodialysis patients?

A. Predictors of sudden cardiac death among HDX were evaluated using data fr. HEMO study. Among 1745 enrolled HDX ptns., there were 808 deaths over 2.5 y.s, 22 % of wch were due to sudden cardiac death. {Age, D.M., peripheral vasc. dis., isch. heart dis., a low s. cr. (reflecting decrease msc mass & poor nutrition) & an increase ALP.} predicted †⮞a higher risk for sudden cardiac death. 

Q.548. What are the technical 💢 considerations regarding CVVHD ?

A. Both convection-based (H.F.) & diffusion-based (H.D.) solute removal techniques are incl. in CRRT. CVVHD provides diffuse solute clearance for management of R.F. in critically ill ptns. To perform CVVHD, a system requires only two fluid management pumps to regulate Dzt inflow & effluent (spent Dzt +U.F.) outflow. A No. of "integrated" CRRT machines represent the standard of care.

Any hemoDzer or hemofilter tht provides sufficient diffusive solute clearance cn be utilized in CVVHD. Synthetic, biocompatible membranes are preferred over cellulosic ones. However AN-69 membranes shd be used é caution é ACEI due to incr. incidence of anaphylactoid reactions. Dzt. composition ⮞same as for other CRRT modalities. Heparin is the most widely used anticoagulant. Regional citrate hs bn used as an alternative to heparin in all modalities of CRRT, incl. CVVHD, é minimum total effluent flow rates for CVVHD = 20-25 mL/kg /h..

Q.549. What is the general considerations of HDX. in the elderly?      

A. Many elderly hv a high quality of life on DX, despite expected limited survival, lending support to offer ESRD therapy to them. Most elderly wd choose DX. if given the therapeutic option, esp. if Sm. were relieved & independence ws maintained.DX should therefore not be denied to elderly, even the very old, if there’s hope for prolongation of an enjoyable span of life. However, DX shd not be used merely to prolong the dying process. When there’s doubt about chances of recovery fr. sev. underlying dis., a "trial " of DX may be offered. Withdrawal of DX é later time is preferable to withholding it fr. the start. Major C.I. to DX: advanced malignancy (except multiple myeloma), irreversible dementia or advanced liver dis.. P.D. or HDX. are the two principal options for RRT in most ptn.s.

Q.550. What are the strategies to minimize dialysis-induced hypotension in the elderly?   🥺🥺

1)   Frequent assessment of D.W.                                                   

2)   Avoid excessive interdialytic Wt. gain (<5 % body Wt.)

3)   Avoid anti-H.T. drugs prior to DX or altogether.

4)   Reduce intake of narcotic analgesics & sedative hypnotics

5)   No heavy meals on, or just prior to DX.

6)   Incr. hematocrit to 33%

7)   Evaluate for silent pericardial effusion

8)   Use Dzt sod. of >140 meq/L

9)   High Dzt calcium.

10) Use bicarbonate DX. (esp. é high QB)

11) Prox. O2, esp. é cardiac or respiratory dis. & preDX PaO2 of < 80mmHg

12) Use biocompatible membrane

13) In selected ptn, use a cool Dzt (34°C!!).

14) Use DX machines é UF controls

15) Use sequential UF-DX; occasionally needed when high UF rates are retired.

16) Ameliorate risk f.s for LVH (anemia, hyperpara., aluminum overload)

17)Improve nutritional status & hypoalbuminemia if present .