What About Heart Failure in Dialysis Patients?
Jan 06, 2023
What kidney patients on hemodialysis are most afraid of is the occurrence of cardiovascular and cerebrovascular accidents, which is also a high-risk death factor for patients with kidney disease on dialysis, increasing the hospitalization rate and mortality of patients. According to relevant literature, nearly 44% of dialysis patients with kidney disease are complicated with mental failure, and more than 1/3 of new dialysis patients have heart failure. Therefore, controlling the psychological failure of dialysis patients with end-stage renal disease is an important measure to improve the quality of dialysis and prolong the quality of life of patients with dialysis. Prevention and treatment, early diagnosis and treatment, and prevention of serious cardiovascular and cerebrovascular accidents.
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This article aims to explain the risk factors of heart failure, types of heart failure, clinical symptoms and diagnosis, treatment, and nursing of hemodialysis patients, hoping to help more kidney patients with kidney disease and dialysis to stay away from heart failure and danger.
These factors include dialysis patients such as hypertension, diabetes, dyslipidemia, and other underlying diseases. Most patients on regular dialysis have high blood pressure. This is due to the loss of the ability to regulate blood pressure, the activation of the renin-angiotensin system, and the excitement of the sympathetic nervous system. Increased load and overloaded lining further induce ventricular remodeling, leading to the occurrence of heart failure. The macrovascular complications and microvascular complications of diabetes and dyslipidemia, as well as diabetic myocardial damage, promote the occurrence of heart disease, and abnormal blood lipids are mainly likely to cause arteriosclerosis and ischemic heart disease.
First of all, the patient's volume load problem, the patient's insufficient dialysis, insufficient ultrafiltration volume, excessive drinking water, etc. cause high volume load and increase the burden on the heart; secondly, the patient frequently suffers from hypotension during dialysis, and the incidence of hypotension is high. It is related to decreased effective blood volume, decreased plasma osmotic pressure, and autonomic nervous dysfunction. Hypotension may lead to myocardial damage caused by insufficient cardiac perfusion and eventually, lead to decreased cardiac function and heart failure. Third, in the majority of patients Susceptible factors, are the main cause of heart failure during infection, especially the cumulative symptoms of heart complications during lung infection; finally, renal anemia, and hemoglobin reduce the oxygen-carrying capacity of the blood, and insufficient oxygen supply causes myocardial damage. Compensated or decompensated work increases.
In the past, it was believed that no matter which dialysis method was used, the symptoms of heart failure could be relieved. Now research has found that different dialysis modes have significant differences in the control of heart failure. Such as dialysate electrolytes, dialysate temperature, calcium and phosphorus metabolism disorder, secondary hyperparathyroidism, and hypercoagulable state, etc.
Early clinical manifestations of hemodialysis heart failure
The early identification of patients with hemodialysis complicated with heart failure mainly includes:
1) The respiratory rate is significantly accelerated, and breathing effort and shortness of breath occur without incentives, especially when the patient is resting.
2) The patient has cyanosis of lips, pale complexion, weakness of limbs, sweating, elevated blood pressure, abnormal heart rhythm and pulse, etc.
3) The patient has decreased urine output within a short period, and there is no other relevant reason to explain the decreased urine output;
4) Rapid weight gain; obvious edema in various parts of the body, etc.
5) The patient has inexplicable coughing, which can be mild or severe, especially when lying on the back, the cough is severe, and when the semi-recumbent or sitting upright, the cough is relieved or there is a slight panting sound, and the breathing is labored.
6) Elderly patients may manifest apathy, fatigue, fatigue, and changes in consciousness. Some elderly patients may even experience a disturbance of consciousness. Mild patients may have symptoms such as unresponsiveness and apathy.
7) The patient has pale lips, increased sweating, rapid pulse, abnormally high blood pressure, or irregular pulse changes.
During the hemodialysis monitoring process, once the patient has any of the above-mentioned symptoms or any discomfort, report to the doctor in time, immediately carry out blood pressure pulse, and respiration checks on the patient and cooperate with the doctor to check the patient's general condition, including various laboratory tests, try to avoid the occurrence of heart failure in the early stage, and reduce the harm caused to patients.
Classification and clinical symptoms of hemodialysis heart failure
Heart failure in MHD patients is divided into two categories: heart failure with preserved ejection fraction (HFpEF) is prevalent in HD patients, whereas heart failure with reduced ejection fraction (HFrEF) affects only a minority of patients. Compared with ordinary patients, the clinical manifestations of heart failure in hemodialysis patients are more atypical, and the prognosis is poorer. Clinicians should attach great importance to early diagnosis and treatment.
Left heart failure: Nocturnal paroxysmal dyspnea, cough, shortness of breath, chest tightness, orthopnea, etc., physical examination shows moist rales in both lungs, diastolic gallop rhythm, etc.
Right heart failure: symptoms of systemic circulation congestion, such as edema of both lower extremities, jugular vein filling, and distension.
What needs to be differentiated clinically is the clinical symptoms of the new coronavirus infection, especially the respiratory system-related symptoms of new coronary pneumonia, such as dyspnea, frequent cough and sputum, chest tightness and shortness of breath, etc., which can be determined by some lung manifestations and blood sample indicators Judgment and treatment distinguish between the respiratory system and the circulatory system. The clinical diagnosis of heart failure can refer to the following indicators: ①Echocardiography is the most commonly used non-invasive method to evaluate cardiac function in dialysis patients. ②Biochemical markers, B-type natriuretic peptide (BNP), and amino-terminal pro-brain natriuretic peptide (NT-proBNP) have important prompting significance for the clinical diagnosis of heart failure and the guidance of curative effect.
Principles of hemodialysis for heart failure
1) Control high blood pressure: control high blood pressure and low blood pressure during dialysis, and avoid excessive fluctuations in blood pressure during dialysis.
2) Control hyperglycemia: Both diabetes and CKD are risk factors for heart failure. Controlling blood sugar is the primary treatment goal for diabetic patients and an important factor affecting the survival rate of dialysis patients.
3) Correct abnormal lipid metabolism
4) Correction of anemia: Effective correction of anemia, but patients with heart failure and hemoglobin ≥ 90g/L are not recommended to be treated with erythropoiesis-stimulating agents (ESAs).
5) Prevention and treatment of chronic kidney disease-abnormal mineral and bone metabolism (CKD-MBD): control bone mineral metabolism disorder, maintain blood calcium, blood phosphorus, and iPTH in the ideal range; control dietary and drug calcium intake, prevent and treat blood vessels and heart valves Calcification.
6) Others: prevention of infection, prevention, and treatment of vascular calcification, correction of hyperhomocysteinemia, anticoagulation, etc.
Symptom control during heart failure attack
In dialysis patients with heart failure, reducing volume overload and improving water and sodium retention and blood pressure control remains key management strategies.
1) Capacity management, ① suggests that patients should have a low-salt diet, and the daily sodium intake should be less than 5g, preferably less than 3g;
② control the weight growth rate between dialysis < 5% of dry body weight;
③ for patients with a significant increase in volume load Patients should appropriately increase the dialysis time, or adopt slow dialysis or night dialysis to avoid rapid fluctuations in patient volume load, and the ideal ultrafiltration rate should be <10-13ml/(kg·h).
④Regularly assess and adjust the dry weight to achieve dry weight up to standard.
For patients with excessive dry weight: chest X-ray examination showing signs of pulmonary congestion; patients with cardiothoracic ratio > 50% in men and > 53% in women and edema before dialysis, ultrafiltration therapy should be actively performed. It is recommended to use methods such as bioelectrical impedance and ultrasound measurement of the inferior vena cava to objectively evaluate the patient's fluid status and detect increased volume load early.
2) The individualized dialysis plan, continuous hemofiltration has more advantages in improving cardiac function than intermittent hemodialysis. It is recommended that heart failure patients with myocardial damage choose CRRT or hemofiltration (HF) to improve heart failure symptoms. For patients with poor self-control ability and excessive weight gain during maintenance hemodialysis, the dialysis time can be extended and the frequency of dialysis can be increased; for patients with hypotension during dialysis, sequential dialysis can be used; antihypertensive drugs should be stopped on the dialysis day.
3) Evaluate the adequacy of dialysis regularly. Patients with single dialysis spKt/V ≥ 1.2 and URR ≥ 65%; guarantee dialysis time, patients who lose residual renal function, hemodialysis time ≥ 12 hours per week; patients with residual renal function > 2ml/min Patients, weekly hemodialysis time ≥ 10h.
4) Others,
①Use ultra-pure dialysate to improve the micro-inflammation state;
②Strengthen the management during dialysis treatment to avoid the occurrence of dialysate overrun;
③Blood return flow rate after dialysis should be slow to prevent patients from rapidly increasing blood volume;
④ For patients with unstable cardiovascular status, it is recommended to use hemofiltration or hemodiafiltration treatment mode;
⑤ Controlling the causes of heart failure and treating concurrent cardiopulmonary diseases All dialysis patients should evaluate the basic etiology and risk factors leading to heart failure and Active treatment.
5) Nursing measures should be kept up to date. When the patient has clinical manifestations of heart failure, the hemodialysis nurse should perform ECG monitoring, finger pulse oxygen monitoring, oxygen inhalation, and raise the head of the bed for the patient before going to the machine. After the doctor evaluates the patient's condition and allows the patient to go After the machine, you can follow the doctor's instructions to start the machine with low flow and low parameters. During the dialysis process, you should strengthen patient inspections, monitor indicators, and judge the changes in the patient's condition. If the patient's condition does not support ordinary dialysis, CRRT treatment may be carried out according to the doctor's advice, and continuous and slow treatment is used to stabilize the patient's condition and solve the patient's load problem.
In conclusion, heart failure is a common complication in patients with end-stage renal disease receiving long-term dialysis. For dialysis patients with heart failure, early identification of clinical symptoms of heart failure and timely hospital treatment can prevent more serious outcomes. In addition, all dialysis patients with kidney disease should work together with clinicians and nurses, and controlling risk factors from the source may be able to reduce the incidence of cardiovascular events to a greater extent. During hemodialysis treatment, clinicians and nurses need to identify the patient's condition promptly and initiate a treatment plan when heart failure is discovered. Strengthen health education related to hemodialysis to avoid the existence of risk factors caused by insufficient dialysis, intemperance of drinking water, avoiding colds and infection, and poor control of complications such as blood sugar, blood pressure, and blood lipids.
for more information:Ali.ma@wecistanche.com
