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Preoperative Risk Assessment and Management in Adults Receiving Maintenance Dialysis and Those With Earlier Stages of CKD.
Bahrainwala, JZ, Gelfand, SL, Shah, A, Abramovitz, B, Hoffman, B, Leonberg-Yoo, AK
American journal of kidney diseases : the official journal of the National Kidney Foundation. 2020;(2):245-255
Abstract
With an increasingly aging population and improved mortality in individuals with end-stage kidney disease, more surgeries are being performed on patients with all stages of chronic kidney disease (CKD). This high-risk population carries unique risk factors that have been associated with increased adverse perioperative outcomes, including acute kidney injury, cardiovascular events, and mortality. In this article, we review the literature describing absolute risks associated with common surgeries performed in patients with CKD and patients receiving maintenance dialysis. We also review perioperative optimization with special risk assessment including evaluation of cardiovascular and bleeding risk evaluation, hypertension management, and timing of dialysis. Predictive model scores are reviewed as a method to stratify risk for acute kidney injury, major adverse cardiac events, or other serious complications with elective surgeries. A multidisciplinary approach with individualized counseling is necessary to counsel the patient with advanced CKD or patients treated with maintenance dialysis considering elective surgery.
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Ocular dialysis disequilibrium-Management of intraocular pressure during hemodialysis of open angle glaucoma: A case report and review of the literature.
Lippold, CL, Kalarn, SP, Swamy, RN, Patel, AM
Hemodialysis international. International Symposium on Home Hemodialysis. 2019;(3):E72-E77
Abstract
It has been shown that patients with end-stage renal disease (ESRD) have an increased risk for changes in intraocular pressure during hemodialysis, or ocular dialysis disequilibrium which can cause pain or discomfort during treatment and lead to decreased vision over time. This is a case of an elderly male with ESRD who was having headaches, nausea, and eye pain during hemodialysis due to increased intraocular pressures. Using a higher sodium prescription resolved his symptoms and normalized his intraocular pressures. This case illustrates that modification in dialysate tonicity can decrease changes in intraocular pressures while patients are on hemodialysis, a vision saving consideration for patients.
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Symptomatic Hyperglycemia in a Patient with Dialysis Ascites.
Vigil, D, Kien, C, Gibb, J, Glew, RH, Tzamaloukas, AH
The American journal of the medical sciences. 2019;(6):512-516
Abstract
An anuric woman with ascites rapidly developed extreme hyperglycemia and seizures after hemodialysis. During development of hyperglycemia, the decrease in serum sodium concentration (Δ[Na]) was nearly twice the value predicted by a formula accounting for the degree of hyperglycemia and the intracellular-to-extracellular volume ratio. The prediction assumed that ascitic fluid is part of the extracellular volume. Potential contributors to the development of seizures include the rapid development of severe hypertonicity, a remote history of seizure disorder and development of dialysis disequilibrium syndrome. Observations in peritoneal dialysis suggest that fluid with sodium concentration lower than in the ascitic fluid is transferred from the abdominal cavity into the blood during rapid development of hyperglycemia. In this case, Δ[Na], which determines the tonicity level expected after correction of hyperglycemia, resulted from exit of both intracellular and ascitic fluid into the extracellular compartment and, therefore, ascitic fluid functions as an extension of the intracellular fluid.
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Young man with severe metabolic acidosis after transformer oil ingestion: a case report.
Khan, FG, Zubair, SM
Journal of medical case reports. 2018;(1):290
Abstract
BACKGROUND Transformer oil is used in oil-filled transformers for its insulating as well as coolant properties. Transformer oil ingestion for attempted suicide is seldom heard of. Our patient's case presented us with a major diagnostic as well as treatment challenge because we encountered such a case for the first time and were totally unaware of the fact that methanol might make up the main component of an aged transformer oil. CASE PRESENTATION A 19-year-old Pakistani/Asian man was brought to our hospital with altered sensorium. He was found to have elevated anion gap acidosis, increased osmolal gap, and acute kidney injury. He had no evidence of rhabdomyolysis or hemolysis. Computed tomography of his head showed cerebral edema. He was resuscitated with intravenous fluids and bicarbonate. Three days later, he confessed taking transformer oil with suicidal intention. His clinical picture mimicked acute methanol intoxication. With an initial improvement in his neurological status, he started complaining of constant headache with episodes of agitation and delirium. His renal function continued worsening despite an adequate urine output. He showed a remarkable improvement in his neurological state after just one session of hemodialysis. CONCLUSIONS There is evidence that aged transformer oil contains methanol, and a patient who consumes it can present with features mimicking acute methanol intoxication.
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[Calcific uremic arteriolopathy in hemodialysis patient, review of literature through five cases reports].
Chettati, M, Adnouni, A, Fadili, W, Laouad, I
Nephrologie & therapeutique. 2018;(6):439-445
Abstract
Calcific uremic arteriolopathy, also called calciphylaxis, is a rare and severe disorder that presents with skin ischemia and necrosis, sometimes it presents with systemic necrosis, the process is secondary to the obliteration of the arterioles first by sub-intimal calcium deposits and then by thrombosis. These lesions can often lead to death due to infectious complications and comorbidities such as diabetes, obesity, arteritis, diffuse vascular calcifications, heart disease and undernutrition. The diagnosis is suggested by the characteristic ischemic skin lesions and their distribution, often bilateral and painful, associeted with calcific uremic arteriolopathy risk factors (phosphocalcic abnormalities, anti-vitamin K). The presence of radiological vascular calcifications is highly suggesting the diagnosis, but remains not very specific. The indication of skin biopsy is rare and reserved for difficult diagnoses. The goals of treatment are: reduce the extension of calcification and treatment of mineral and bone metabolism disorders of end-stage renal disease, dialysis adequacy, local treatment of skin lesions, tissue oxygenation, pain management, discontinuation and contraindication of medications that may contribute to the disorder. We propose to discuss it from a review of the literature and illustrate it with five clinical cases.
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6.
Sudden Cardiac Death Among Hemodialysis Patients.
Makar, MS, Pun, PH
American journal of kidney diseases : the official journal of the National Kidney Foundation. 2017;(5):684-695
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Abstract
Hemodialysis patients carry a large burden of cardiovascular disease; most onerous is the high risk for sudden cardiac death. Defining sudden cardiac death among hemodialysis patients and understanding its pathogenesis are challenging, but inferences from the existing literature reveal differences between sudden cardiac death among hemodialysis patients and the general population. Vascular calcifications and left ventricular hypertrophy may play a role in the pathophysiology of sudden cardiac death, whereas traditional cardiovascular risk factors seem to have a more muted effect. Arrhythmic triggers also differ in this group as compared to the general population, with some arising uniquely from the hemodialysis procedure. Combined, these factors may alter the types of terminal arrhythmias that lead to sudden cardiac death among hemodialysis patients, having important implications for prevention strategies. This review highlights current knowledge on the epidemiology, pathophysiology, and risk factors for sudden cardiac death among hemodialysis patients. We then examine strategies for prevention, including the use of specific cardiac medications and device-based therapies such as implantable defibrillators. We also discuss dialysis-specific prevention strategies, including minimizing exposure to low potassium and calcium dialysate concentrations, extending dialysis treatment times or adding sessions to avoid rapid ultrafiltration, and lowering dialysate temperature.
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Dialysate and serum potassium in hemodialysis.
Hung, AM, Hakim, RM
American journal of kidney diseases : the official journal of the National Kidney Foundation. 2015;(1):125-32
Abstract
Most patients with end-stage renal disease depend on intermittent hemodialysis to maintain levels of serum potassium and other electrolytes within a normal range. However, one of the challenges has been the safety of using a low-potassium dialysate to achieve that goal, given the concern about the effects that rapid and/or large changes in serum potassium concentrations may have on cardiac electrophysiology and arrhythmia. Additionally, in this patient population, there is a high prevalence of structural cardiac changes and ischemic heart disease, making them even more susceptible to acute arrhythmogenic triggers. This concern is highlighted by the knowledge that about two-thirds of all cardiac deaths in dialysis are due to sudden cardiac death and that sudden cardiac death accounts for 25% of the overall death for end-stage renal disease. Developing new approaches and practice standards for potassium removal during dialysis, as well as understanding other modifiable triggers of sudden cardiac death, such as other electrolyte components of the dialysate (magnesium and calcium), rapid ultrafiltration rates, and safety of a number of medications (ie, drugs that prolong the QT interval or use of digoxin), are critical in order to decrease the unacceptably high cardiac mortality experienced by hemodialysis-dependent patients.
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Dialysate Calcium Concentration, Mineral Metabolism Disorders, and Cardiovascular Disease: Deciding the Hemodialysis Bath.
Langote, A, Ahearn, M, Zimmerman, D
American journal of kidney diseases : the official journal of the National Kidney Foundation. 2015;(2):348-58
Abstract
Patients with end-stage kidney disease treated with dialysis are at increased risk to experience fractures and cardiovascular events than similar-aged people from the general population. The enhanced risk for these outcomes in dialysis patients is not completely explained by traditional risk factors for osteoporosis and cardiovascular disease. Mineral metabolism abnormalities are almost universal by the time patients require dialysis therapy, with most patients having some type of renal osteodystrophy and vascular calcification. These abnormalities have been linked to adverse skeletal and cardiovascular events. However, it has become clear that the treatment regimens used to modify the serum calcium, phosphate, and parathyroid hormone levels almost certainly contribute to the poor outcomes for dialysis patients. In this article, we focus on one aspect of mineral metabolism management; dialysate calcium concentration and the relationships among dialysate calcium concentrations, mineral and bone disorder, and cardiovascular disease in hemodialysis patients.
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Idiopathic erythrocytosis in dialysis patients: a case report and literature review.
Sheqwara, J, Alkhatib, Y, Dabak, V, Kuriakose, P
American journal of nephrology. 2013;(4):333-8
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Abstract
Anemia is a common complication in end-stage renal disease (ESRD) patients. On the other hand, idiopathic erythrocytosis is extremely rare, with only a few cases reported in the literature. We present a case of erythrocytosis that developed after initiating hemodialysis. A 68-year-old male with a history of ESRD secondary to diabetes presented with erythrocytosis that started a few months after initiating dialysis in the absence of having received erythropoietin-stimulating agents or iron supplements. His erythropoietin level was elevated, with a negative JAK2 mutation. Blood gases showed normal oxygen and CO(2), with slightly elevated carboxyhemoglobin. Tiny foci in both kidneys were noted, representing vascular calcifications or renolithiasis. There was no radiological evidence of neoplasms or cysts. After excluding secondary causes, a diagnosis of idiopathic erythrocytosis was made. The patient underwent intermittent phlebotomies during dialysis, and his hemoglobin went from 18.5 to 14 mg/dl. Erythrocytosis in ESRD patients is very rare. So far, there is no complete understanding of the underlying pathophysiology; however, there seem to be multiple possible reasons for an increased erythropoietin level. Phlebotomy is a successful and easy way to control erythrocytosis in such patients. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, currently being used in posttransplant erythrocytosis, might also be considered.
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Cushing's syndrome after hemodialysis for 21 years.
Mise, K, Ubara, Y, Sumida, K, Hiramatsu, R, Hasegawa, E, Yamanouchi, M, Hayami, N, Suwabe, T, Hoshino, J, Sawa, N, et al
The Journal of clinical endocrinology and metabolism. 2013;(1):13-9
Abstract
CONTEXT Hyperkalemia and weight loss are critical clinical problems for hemodialysis patients. There have been no documented reports of adrenal Cushing's syndrome with central obesity and hypokalemia in a hemodialysis patient. OBJECTIVE The aim of the study was to report a patient with Cushing's syndrome after chronic hemodialysis, review the published literature, and discuss the significance of hypokalemia and obesity in anuric hemodialysis patients from the perspective of cortisol metabolism. PATIENT A 61-yr-old woman who had been on hemodialysis for 21 yr presented with persistent hypokalemia and central obesity. In 2002, her dry weight was 48.1 kg, but thereafter she gained weight to 60 kg. RESULTS Adrenal Cushing's syndrome was diagnosed from endocrinological findings such as increased cortisol secretion without a circadian rhythm and suppression of plasma ACTH. Spironolactone was administered (25 to 50 mg/d), and her serum potassium became normal. Then, left adrenalectomy was performed by laparoscopic surgery. The resected specimen contained a well-circumscribed adrenal adenoma expressing P450c17. After surgery, hypokalemia improved gradually without medication, and her weight gain stopped. CONCLUSIONS This is the first documented case of adrenal Cushing's syndrome in a patient on long-term hemodialysis, although several authors have reported a relation between hypokalemia and primary hyperaldosteronism in hemodialysis patients.