Table 1.
General Strategy | Specific Intervention |
---|---|
Manage cardiomyopathy | |
Systolic Dysfunction | Use carvedilol in patients with dilated cardiomyopathy |
Diastolic dysfunction/LVH | Consider more frequent HD to reduce left ventricular mass; consider use of spironolactone, ACE inhibitors, or ARBs |
Minimize arrhythmic triggers | |
Potassium shifts | Monitor pre-dialysis potassium frequently, especially after hospitalization and change dialysate bath accordingly; avoid low (< 2 mEq/L) potassium baths; consider potassium modeling and potassium binding agents to reduce interdialytic hyperkalemia |
Calcium shifts | Avoid low (< 2.5 mEq/L) calcium baths, especially with concurrent use of QT interval prolonging medications |
Metabolic alkalosis | Avoid high dialysate bicarbonate concentrations in alkalotic patients; account for all sources of base in dialysate, including acetate |
Rapid ultrafiltration | Encourage patient adherence to salt and fluid restrictions; avoid sodium ramping and large dialysate/serum sodium gradients; extend dialysis time so that ultrafiltration rates do not exceed 10 ml/kg/hr |
Dialysis-induced myocardial ischemia | Lower dialysate temperature to between 0.5°C and 2°C below patient temperature to reduce intradialytic hypotension |
Medications | Avoid QT interval prolonging medications whenever possible and reconcile medication list regularly |
Weigh risks and benefits of ICDs | Consider ICDs for secondary prevention; increase communication between nephrologists and cardiologists to consider risks and benefits of primary prevention ICDs; consider leadless defibrillators to reduce vascular and infectious risks |
Improve response to cardiac arrest | Increase dialysis clinic staff awareness of cardiac arrest risk and readiness to provide basic life support; encourage awareness and CPR training among patients and families |
Adapted from Pun103 with permission of Elsevier.
Abbreviations: HD, hemodialysis; LVH, left ventricular hypertrophy; ACE inhibitors, angiotensin converting enzyme inhibitors; ARBs, angiotensin receptor blockers; ICDs, implantable cardioverter defibrillators; CPR, cardiopulmonary resuscitation