Critical care Nephrology combine conference

1. Critical care Nephrology combine conference R4李宗育/ VS吳允升

2. A 69 year-old man with bilateral lower legs pitting edema for one month

3. Past history • Systemic diseases: • ESRD under hemodialysis from 1998~2004, status renal transplantation in 2004 • Asthma • Regular medications: • Lasix 40 mg/tab 1 tab BID • HARNALIDGE D 0.2 mg/tab • Tonsaric 100 mg/tab 1 tab QD • CellCept 250 mg/cap 3 cap BID • 0.5 Prograf 0.5 mg/cap 1 cap QD • Allergy: NKA

4. Past history • Hospitalization: • Renal transplantation (2004/7/30) • Right radial shaft and right ulnar shaft fracture, proximal third, status post internal fixation (2010/12/7) • Right ulnar shaft fracture, proximal third, status post internal fixation, with nonunion and implant failure(2011/9/29) • Smoking: no, Drinking: no, Betel nuts: no • Occupation: nil • Recent travel: nil • Contact and cluster history: nil

5. Family History

6. Serial renal function

7. 2012/01/05 Graft Kidney Echo

8. Physical Examination • General appearance: fair. • Consciousness: clear, Activity: well. • HEENT: gross anomaly • Conjunctiva: not pale; Sclera: not icteric • Pupils: isocoric, Light reflex: +/+, prompt • Neck: supple, LAP (-). • Chest: symmetric expansion, no retraction; breath sound: bilateral clear. wheezing (-), rhonchi (-), rales(-).

9. Physical Examination • Heart: regular heart beat, with no murmur. • Abdomen: soft and ovid, bowel sound: normoactive, tenderness (-), rebound pain (-). liver/ spleen: impalpable. • Extremity: freely movable, cyanosis (-), pitting edema (+). • Skin: no ecchymosis, rash (-), petechiae (-), ecchymosis (-).

10. Lab

11. Lab

12. Lab

13. ECG 2012/03/12

14. CXR 2012/03/12

15. Percutaneous Nephrostomy on 3/13 • Middle graft ureter stenosis with moderate hydronephrosis of the graft kidney. the bladder was opacified, partial obstruction is considered. • DBJ(7Fr 14cm, Inlay, Bard) • PCN with 8Fr pigtail catheter

16. Percutaneous Nephrostomy on 3/13 • Middle graft ureter stenosis with moderate hydronephrosis of the graft kidney. the bladder was opacified, partial obstruction is considered. • DBJ(7Fr 14cm, Inlay, Bard) • PCN with 8Fr pigtail catheter

17. PCN revision on 3/14 • Much filling defect in the graft renal pelvis, graft ureter, and bladder, large blood clots is considered • PCN was performed via exchanging with a larger bore 10Fr pigtail catheter in the graft renal pelvis. hematuria was noted, Diluted bosmin was transcatheter injected into the bladder

18. PCN revision on 3/14 • Much filling defect in the graft renal pelvis, graft ureter, and bladder, large blood clots is considered • PCN was performed via exchanging with a larger bore 10Fr pigtail catheter in the graft renal pelvis. hematuria was noted, Diluted bosmin was transcatheter injected into the bladder

19. CT guide PCN on 3/19 • Bloody hematuria was aspirated, much blood clots in the graft renal pelvis was noted, diluted bosmin was transcatheter injected into the graft renal pelvis. suggest clamp the PCN for 30 minutes.

20. CT guide PCN on 3/19 • Bloody hematuria was aspirated, much blood clots in the graft renal pelvis was noted, diluted bosmin was transcatheter injected into the graft renal pelvis. suggest clamp the PCN for 30 minutes.

21. Lab 3/13 PCN+DBJ 3/14 PCN revision 3/19 PCN HD

22. Hyponatremia workup

23. Tentative diagnosis • Acute on choronic kidney injury, RIFLE F, susp. post-renal factor, sepsis or bleeding related complicated with uremic encephalopathy, metabolic acidosis and hyponatremia • End stage renal disease, under hemodialysis statsu post kidney transplantation in 2004 • Hypertension • Asthma

24. Discussion Renal replacement therapy in patient with hyponatremia

25. Hyponatremia • Hyponatremia is common in seriously ill patients requiring acute dialysis • Such patients often have received large amounts of hyponatric intravenous solutions with their medications and parenteral nutrition. Handbook of Dialysis, Fourth Edition

26. Predialysis serum sodium level > 130 mmol/L • If the patient is to undergo an average efficiency, 4-hour dialysis, then a postdialysis serum sodium level of 140 mmol/L can be achieved by setting the dialysis solution sodium concentration level: 140 + ( 140 – predialysis serum sodium value) Handbook of Dialysis, Fourth Edition

27. Predialysis serum sodium level < 130 mmol/L • When the degree of predialysis hyponatremia is moderate to severe, and especially if the hyponatremia is of long duration, it may be dangerous to achieve normonatremia quickly. • Rapid correction of hyponatremia has been linked to a potentially fatal neurologic syndrome known as osmotic demyelination syndrome. Handbook of Dialysis, Fourth Edition

28. Correction of the serum sodium • The rate of correction of asymptomatic chronic hyponatremia should not exceed 0.5 mEq/L/hr, 10 mEq/L in the first 24 hours, and not more than 18 mEq/L in the first 48 hours. • In symptomatic hyponatremia, the correction rate may go up to 1.5–2mEq/L/hr for the first 3–4 hours, but still not exceeding 12mEq/L in the first 24 hours. Am Soc Nephrol 4:1522–1530, 1994

29. Osmotic demyelination syndrome • Demyelination in the pons and extrapontine areas, is manifested by spastic quadriparesis, pseudobulbar palsy, and mental disorders ranging from confusion to coma. • When chronic hyponatremia is corrected rapidly, blood becomes relatively hypertonic to the brain, and osmotic stress shifts water out of the brain. • A “dehydrated” brain results in myelinolysis and demyelination syndrome. Renal Failure, 29:635–638, 2007

30. Osmotic demyelination syndrome--Neurologic Findings • The classic symptoms are spastic quadriparesis and pseudobulbar palsy, which occur as a result of corticospinal and corticobulbartract involvementin the pons and internal capsule. • Most patients show early impairment of consciousness, which sometimes leads to coma. • Bilateral cerebral or thalamic damage, or lesions in the ascending reticular activating system in the brainstem or pons, may result in altered consciousness AJR 2004;182:809–816

31. Osmotic demyelination syndrome • However, in uremic patients with hyponatremia, demyelination syndrome following the correction of hyponatremiaduring hemodialysis is rare. • Uremiawas considered a possible protective factor. • A recent report described a patient with acute on chronic renal failure and hyponatremiawho tolerated hemodialysis well without any neurological effects despite a serum correction of sodium rate of 3 mEq/L/hr. Semin Dial. 2003;16:68–71

32. Osmotic demyelination syndrome

33. Predialysis serum sodium level < 130 mmol/L • The maximum safe rate of correction of the serum sodium concentration in severely hyponatremic patients is controversial. • Long standing hyponatremia to set the dialysis solution sodium level no higher than 15-20 Mm above the plasma level, with the goal of correcting hyponatremia during multiple dialysis treatments performed over several days. Handbook of Dialysis, Fourth Edition Semin Dial. 1990;3:3–4.

34. PROPOSED DIALYSIS PRESCRIPTION FOR OUR PATIENTSWITH SEVERE HYPONATREMIA • Na: 116mmol/L • The lowest Na setting on our dialysis machines is 130 mmol/L. • We started with a dialysis time of 2 hours (120 min). • Estimated total body water = 40L (80kg) • We attempted to limit the rise in serum Na to 2 mmol/L/hr (4mmol/L x 40L = 160 mmol) added to the patients TBW for the entire HD treatment. • The patient would have 14 mmol(130-116) Na added to the blood for every L of clearance. • Limited total clearance: 160/14= 11L • Holding clearance to only 11000 ml in 120 min required a reduction on blood flow to approximately 90 ml/min.

35. Management of sodium disorders duringcontinuous haemofiltration • Continuous venovenous haemofi ltration (CVVH) is an established treatment for patients with acute kidney injury. • During CVVH, serum electrolyte concentrations tend to equilibrate with their concentrations in the replacement fluid. • If CVVH is needed, the Na+ concentration in the replacement fluid (usually 140 mmol/l) needs to be adjusted in order to avoid rapid changes of the serum Na+ concentration. Critical Care 2010, 14:418

36. Management of sodium disorders duringcontinuous haemofiltration • Generally, it is not considered safe to increase the serum Na+ concentration by more than 8 to 10 mmol/l over 24 hours, especially in chronic hyponatraemia. • If the serum Na+ concentration has increased by >2 mmol/l in 6 hours, either the rate of filtration should be decreased or the fluid bags should be changed to bags with a lower Na+ concentration. Critical Care 2010, 14:418

37. Critical Care 2010, 14:418

38. Take home message • Anuric hyponatremic patients present a therapeutic dilemma, as hemodialysis may expose them to rapid sodium [Na] and osmotic demyelination. • Long standing hyponatremia to set the dialysis solution sodium level no higher than 15-20 Mm above the plasma level, with the goal of correcting hyponatremia during multiple dialysis treatments performed over several days. • CVVH may be one of the choice

39. Thank you for your attention