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Wang E, Kim S, Wang A, Jiang W, Shah A. Peritoneal dialysis in the setting of acute brain injury: an underappreciated modality. Hosp Pract (1995) 2023; 51:175-183. [PMID: 37491156 DOI: 10.1080/21548331.2023.2241340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 07/12/2023] [Accepted: 07/24/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION Dialysis is complicated in the setting of acute brain injury (ABI) due to several factors including acute solute shifts, acid base changes, need for anticoagulation, and changes in intracranial pressure. For these reasons, continuous renal replacement therapy (CRRT) is often the chosen modality for renal replacement needs in these patients. Peritoneal dialysis (PD) is less discussed but shares many of the benefits often attributed to CRRT. We describe, from both nephrology and neurosurgical perspectives, a case successfully managed with PD. CASE A 25-year-old male with history of end-stage kidney disease (ESKD) secondary to focal segmental glomerulosclerosis on continuous cycling PD for 5 years presented to the hospital with headache and altered mental status. Initial imaging revealed a large intraventricular hemorrhage extending to the fourth ventricle. He underwent an emergent right depressive hemicraniectomy and clot evacuation. Post-operative imaging revealed worsening cerebral edema, intraventricular hemorrhage, and hydrocephalus. The decision was made to continue PD, noting that it retains many of the benefits of CRRT (which it is in fact, a form of) which he tolerated well until the need for a percutaneous gastrostomy tube arose. He was transiently transitioned to hemodialysis but returned to PD once his gastrostomy healed. He continued PD for 1 year without complication and eventually received a kidney transplant. DISCUSSION In managing patients with ABI undergoing dialysis, a number of considerations must be undertaken including avoidance of hypotension to maintain cerebral perfusion pressure and minimize ischemia reperfusion injury, avoidance of anticoagulants that can precipitate or worsen bleeding, the potential for cerebral edema due to rapid solute clearance and osmotic dissipation of therapeutic hypernatremia, and the mitigation of intracellular acidosis from bicarbonate delivery. Although underutilized, PD may potentially serve as a viable option for dialysis in the setting of ABI as demonstrated by the case presented.
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Affiliation(s)
- Elaina Wang
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Steven Kim
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Aaron Wang
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Winston Jiang
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Ankur Shah
- Warren Alpert Medical School, Brown University, Providence, RI, USA
- Division of Kidney Disease and Hypertension, Rhode Island Hospital, Providence, RI, USA
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Sato K, Konta Y, Furuta K, Kamizato K, Furukawa A, Ono A, Ogawa R, Sato R, Endo K, Yamamoto T. Prognostic factors for acute ischemic stroke in patients undergoing hemodialysis. Clin Exp Nephrol 2021; 26:286-293. [PMID: 34767098 PMCID: PMC8847285 DOI: 10.1007/s10157-021-02146-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 09/28/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Acute ischemic stroke (AIS) is a critical complication in patients undergoing dialysis. Although the improvement of AIS management is an urgent requirement, few studies have evaluated the prognostic factors of AIS in these patients. This study aimed to assess the relationship between clinical factors in patients undergoing dialysis and the prognosis of AIS. METHODS Among 1267 patients who were hospitalized for AIS in Sendai City Hospital from January 2015 to June 2020, 81 patients undergoing hemodialysis were retrospectively enrolled. Multivariate analysis was performed to evaluate the effect of baseline characteristics, dialysis factors, and neurological severity of patients at admission [National Institutes of Health Stroke Scale (NIHSS) score] on in-hospital mortality, physical disability, and the need for rehabilitation transfer. RESULTS A higher NIHSS score was a critical risk factor for each outcome and the only significant factor for in-hospital mortality [odds ratio (OR)/point 1.156, 95% confidence interval (CI) 1.054-1.267]. The risk factors of physical disability were NIHSS score (OR/point 1.458, 95% CI 1.064-1.998), older age (OR/year 1.141, 95% CI 1.022-1.274), diabetic nephropathy (OR 7.096, 95% CI 1.066-47.218), and higher premorbid modified Rankin scale (mRS) score (OR/grade 2.144, 95% CI 1.155-3.978); while those of rehabilitation transfer were a higher NIHSS score (OR/point 1.253, 95% CI 1.080-1.455), dialysis vintage (OR/year 1.175, 95% CI 1.024-1.349), and intradialytic hypotension before onset (OR 5.430, 95% CI 1.320-22.338). CONCLUSIONS Along with neurological severity, dialysis vintage, intradialytic hypotension, and diabetic nephropathy could worsen the prognosis of patients with AIS undergoing hemodialysis.
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Affiliation(s)
- Koji Sato
- Division of Internal Medicine, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Yusuke Konta
- Division of Internal Medicine, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Kyohei Furuta
- Division of Internal Medicine, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Kenyu Kamizato
- Division of Internal Medicine, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Akiko Furukawa
- Division of Internal Medicine, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Akiyuki Ono
- Division of Neurology, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Ryo Ogawa
- Division of Neurology, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Ryosuke Sato
- Department of Clinical Engineering, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Kaoru Endo
- Division of Neurology, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Tae Yamamoto
- Division of Internal Medicine, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan.
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