Amyloidosis is a rare but well-known complication of most of the long term illness. It is the deposition of abnormally folded proteins in the body compartments. However, we see a type of amyloidosis in patients with Chronic Kidney Diseases (CKD) and chronic hemodialysis. This is termed as dialysis related amyloidosis (Beta 2 Amyloidosis). Additionally This type of amyloidosis has found in patient with severe renal impairment, but has not undergone any dialysis.
Mechanism of Dialysis Related Amyloidosis
Our kidney is the most vital organ for the excretory functions of the body. Usually, it removes all the excess chemicals from the body. Beta 2 macroglobulin is also filtered out from the kidney. However, When someone has chronic kidney disease, they have to undergo regular hemodialysis to maintain regular kidney functions. But the artificial dialysis membrane fails to filter out the type of macroglobulin called beta 2 macroglobulin (a type of small protein) from the body.
The failure to remove the beta-amyloid associated macroglobulin can cause the accumulation of them in the body compartments. Some of the sites are the joints and synovium, heart, tongue, and some other organs.
Complications of Dialysis Associated Amyloidosis
Depending on the site of the deposition of the Beta 2 globulin, it cause different clinical signs and symptoms. Most often these patients presenting with chronic joint pains. However in addition to joint pains dialysis related amyloidosis causes lot of different clinical features.
Chronic joint pain
Carpal tunnel syndrome
Cardiomegaly
Heart failure
Macroglossia (large tongue)
Bone fractures
Carpal tunnel syndrome in a Chronic Dialysis patient.
How to Prevent Dialysis Related Amyloidosis
All the patients who undergo chronic dialysis are prone to get dialysis-associated amyloidosis. It is estimated to have 50% of patients getting dialysis related amyloidosis with in 10years of dialysis. Additionally most of the treatment methods for dialysis associated beta 2 amyloidosis fail to completely cure the complications like chronic joint pains, bone destructions and etc.
Therefore it is essential to take adequate precautions to prevent this conditions in all patients undergoing hemodialysis.
Young patients are more prone to get dialysis associated amyloidosis as they are getting more dialysis. Therefore it is better to transplant them early as possible. Longer the duration of dialysis , higher the risk of DAA.
Early kidney transplant is the best method to prevent dialysis related amyloidosis.
However some of the patient with End stage kidney failure may not fit enough to undergo kidney transplant. In such situations we have to take some other methods to prevent this condition.
Most importantly maintaining the residual kidney function is necessary. This will patient own kidneys to function with limitations. As a result, kidneys are able to remove some of the beta 2 macro globulins from the body.
The percentage of beta 2 amyloidosis increase when we use low flux dialyzers. Therefore it is advisable to use high flux dialyzers. When we use high flux dialyzers, a larger pore size allows the dialyzer to remove globulins from the blood.
In addition to the dialyzer, there is important role of dialysate solutions. Therefore always use high quality dialysis solutions in each dialysis.
Some centers also use beta 2 macroglobulin filters to remove beta 2 globulins from the blood. This also reduce the plasma level of beta 2 globulins. As a result there is less chance of accumulation of amyloids in the body tissues.
Related articles
Bardin T, Zingraff J, Kuntz D, Dru¨ eke T. Dialysis related amyloidosis. Nephrol Dial Transplant 1986; 1: 151–154
Zingraff J, Noe¨l LH, Bardin T, et al. Beta-2-microglobulin amyloidosis in chronic renal failure (letter). N Engl J Med 1990;323: 1070–1071
Haemodialysis is an artificial process to provide someone’s kidney functions externally via a machine called dialysis machine. Therefore Haemodialysis is very important process to maintain kidney functions in patients with Chronic Kidney Diseases and some acutely ill patients.
Why do we do dialysis in patients?
Your kidney have very important set of functions to maintain balance between lots of body functions. This includes excretion of waste products, removal of excess water from the body, maintain electrolyte balance, maintain acid base balance and etc. If someone fail to maintain these kidney functions, they will be facing lot of problems Eg:
Accumulation of water in the lungs (Pleural effusion)
Accumulation of water in abdomen (Ascites)
Excess Potassium in the serum (Hyperkalemia)
Reduced pH in the blood (Acidosis)
As most of above issues are life threatening timely dialysis is very important.
How need hemodialysis?
As mentioned, there are two groups of patients who need dialysis.
Patients with Chronic Kidney Diseases (CKD)
Acutely ill patient with Acute kidney injury (AKI)
Dialysis of CKD patients
Hemodialysis is one of the very important option in management of CKD patients. It will help to maintain most of the kidney functions. This will ensure;
Removal of excess fluid from the body
Remove excess Potassium from the plasma
Maintain acid base balance
Dialysis of AKI patients
There are patients who get Acute Kidney Injuries (AKI) following different incidents. Viper bites, Sepsis, Leptospirosis are some of them. In such situations some patients undergo urgent haemodialysis.
How to dialysis a patient?
When we say dialysis most of the time it represents hemodialysis than the peritoneal dialysis. When we do haemodialysis, the basic of this process is to take blood out of the body, purify it and re transfuse into the body. But this is very complicated process than this.
Steps of hemodialysis
Prepare the dialysis machine
Heparinize the vascular set properly
Connect the patient through Vascular access to the dialysis machine
Adjust all parameters of dialysis including UF, BFR, Heparin dose and etc
Let blood go through the semipermeable membrane of the dialyzer
Re transfuse blood to the patient
Reinfuse the blood after completion of procedure
Disconnect the Vascular line
Await for hemostasis
Important parts of Dialysis procedure
image source : Wikipaedia
What is dialyzer?
As I mentioned, dialysis is an artificial process. So to give you kidney functions artificially, there should be an artificial kidney. Dialyzer is the one doing the function of an artificial kidney in the dialysis machine.
The dialyzers are made of synthetic semi permeable membranes. These membranes are capable of providing selective permeability to some of the molecules while others do not get it. So dialyzer is the most important part of the haemodialysis machine.
Vascular access
When you want to undergo haemodialysis, you need to have an access point. This may be a AV Fistula, AV Graft, Perm Cath or Temporary Catheter. So each have different abilities. You should select your vascular access depending on your future dialyzing plan, vascular structure and lots of other factors.
However if you are undergoing an urgent haemodialysis, you have to use a temporary femoral or neck vascular catheter.
The vascular access will ensure the adequate blood supply to the dialysis machine. Also it will return all the purified blood to body.
Water supply
In a dialysis we are doing an invasive procedure to ensure the renal functions of the patient. However if we do not use proper water for this process, patients ended up with lot of complications. Sepsis is one of them.
Therefore we use a water plant with reverse osmotic systems. This includes both filtering capacity of unnecessary particles and germs.
Complications of Haemodialysis
Although haemodialysis is a very important and effective treatment method, it may have lot of complications.
I often see incidents of hypoglycemia during dialysis sessions. This is a common complication of dialysis in most of the hemodialysis centers. Although hypoglycemia is one of the very common complication during haemodialysis, more often inexperienced clinicians may miss these incidents. This article is mainly focus on how to detect hypoglycemia early, how to manage hypoglycaemia and how to prevent it.
Why is the hypoglycemia very common complication during dialysis?
It is true that we often see the patient undergoing clinical and subclinical hypoglycemia during dialysis. But why the dialysis patients are more proven to get hypoglycemic attacks. Is it the dialysis which causing the hypoglycemia? Or some other cause.
Diabetes mellitus can make you hypoglycemic
We know that one of the most common cause for CKD is the diabetes. Patients with diabetes often has high blood sugar levels. This is due to the insulin insensitivity or lack of insulin. So can these patients undergo hypoglycemia during hemodialysis?
Some of these CKD patients on Metformin, some are on other oral hypoglycemic agents like Gliclacide. Even if the metformin do not cause significant hypoglycemia, some other medications can cause the hypoglycemia. In addition Insulin can cause on and off hypoglycaemic events.
Kidney disease can also cause hypoglycemia
Gluconeogenesis is the process of creating glucose inside the body. This mainly occurs when you are in a fasting state. The kidneys are the second most vital organ for this mechanism. It is second only to the liver. When you have CKD, structure of your kidney get damaged and ability of gluconeogenesis is also get reduced. As a result body fails to maintain the adequate amount of the blood sugar levels during dialysis or even at the day to day settings.
Mechanism of dialysis
Dialysis is a complicated process. There is a 15g to 20g of glucose loss during each dialysis session. This loss of plasma glucose can lead to subclnical hypoglycemia in most of the patients. However in some patients they are not fit enough to maintain this loss of glucose during dialysis. Therefore they can get a significant hypoglycemia during dialysis.
Therefore hypoglycemia during dialysis is a multifactorial complication. Although loss of glucose during dialysis do not cause significant symptoms, failure to maintain the gluconeogenesis causing the significant damage to the patient.
How to identify the hypoglycemia during dialysis?
In a usual setting an experienced healthcare professional can identify the hypoglycemic events easily. But during dialysis it is very difficult to identify the hypoglycemic events. As an experienced clinician I have met patients with blood sugar levels of 20mg/dl but they were almost normal except few symptoms. But this is not a viable blood sugar level in a normal patient. Therefore you need to have clear understanding about hypoglycemia during dialysis. If you are not specifically look it, you can’t identify most of the hypoglycemia during haemodialysis.
Symptoms of hypoglycemia during dialysis sessions
Hypotensive attacks Hypotension is the main symptom of low blood sugar levels during dialysis. If a patient develop a hypotension during dialysis, 1st thing to look is the hypoglycemia. Most of the times it is low blood sugar levels than the depletion of volume or some other cause.
Failure to maintain blood pressure with inotropes This is a common issue with patients undergoing the urgent hemodialysis due to Acute Kidney injuries. Most of they are critically ill and on inotrope support. But if a patient do not improve with proper inotrope support, we have to look for the hypoglycemia.
Altered level of consciousness Level of consciousness is a broad term. It include the orientation, the way of talking, level of intelligence and lot of other factors. In some instances I have met CKD patient with less than 20mg/dl blood sugar level with no significant alteration of consciousness.
Case 1. 27years old patient came to regular hemodialysis. He maintained his blood pressure levels and saturation well. No complaints too. But when I talk to him, I found some irrelevance of his sentence to each. I had some suspicion and checked the blood sugar level. It was 17mg/dl and immediate actions were taken.
Case 2. 54years old patient was in his regular haemodialysis. He was given a cup of tea while he was on dialysis. But the staff member noted that he failed to take his tea. He informed me. Then I asked for a blood sugar level. It was 27mg/dl and he was collapsed in few second. Immediate resuscitation was conducted and successfully recovered the patient.
Sweating during dialysis Sweating is a very common symptom of hypoglycemia. You can see it even in patients taking medication for diabetes. However surprisingly I rarely met hypoglycemic patients with sweating during dialysis. So I think you have a clear understanding on symptoms of hypoglycaemia during dialysis sessions. Then the next question is how to manage the hypoglycaemia during dialysis.
How to manage hypoglycemia during dialysis?
As I mentioned events of hypoglycemia is common and subclinical most of the times. However there are times you have to attend on events of hypoglycemia. Even if the pre dialysis and intradialysis blood sugar monitoring can be done, it is not a good and presence experience to patients. Even though the basic management of hypoglycemia is same in each complication, you have to attend the case depend on the symptoms too.
Hypoglycemia with hypotention.
Here the management of both hypoglycaemia and the hypotension should be done simultaneously.Soon as you note there is a hypotension the next action is to check the hypoglycemia.
Start bolus of 100cc normal saline
Give 1 vial of dextrose
Reduce the blood flow rate and position the patient
Repeat the blood pressure and blood sugar in 10 minutes
If blood sugar is not enough repeat the dextrose infusion
Hypoglycemia with no response to inotropes
Inotropes are the medications to improve the blood pressure in critical patients. They have different actions. It is common that patient face significant reduction of blood pressure soon as they are connected to the dialysis machines. But it can be picked up with these medications. But if these patients do not improve the blood pressure with inotrope, it is worth to check the blood sugar level than next inotrope.
Hypoglycemia with altered level of consciousness
Hypoglycemia is not the only cause for altered level of consciousness during dialysis. There are lot of cause like electrolyte imbalance, stoke and etc. In addition there is a very important condition called Dialysis disequilibrium syndrome.
But before thinking of anything else, you should focus on hypoglycemia during dialysis. Because it is easily preventable cause for altered level of consciousness during dialysis.
Whenever a patient has a reduce level of consciousness;
Check the blood pressure
Check the blood sugar levels
Look at the other neurological features
Give bolus of dextrose irrespective of blood sugar levels unless it is too high
Then only you can exclude other causes of altered level of consciousness.
Hypoglycemia with sweating during dialysis
Sweating is another presentation of hypoglycemia. But when someone has the sweating, it myocardial infarction should be ruled out.
Check all vital parameters
Give dextrose
Check urgent ECG
How to prevent hypoglycemia during dialysis
Although hypoglycemia is commonly missed as subclinical incidents, we have to be prepared and look into it properly.
Ask patient to have proper meal prior to dialysis
Arrange a mid-dialysis snack or refreshment
Monitor CBS in high risk patients
Reference:
Vadakedath, S., & Kandi, V. (2017). Dialysis: A Review of the Mechanisms Underlying Complications in the Management of Chronic Renal Failure. Cureus, 9(8), e1603. https://doi.org/10.7759/cureus.1603
Abe, M., & Kalantar-Zadeh, K. (2015). Haemodialysis-induced hypoglycaemia and glycaemic disarrays. Nature reviews. Nephrology, 11(5), 302–313. https://doi.org/10.1038/nrneph.2015.38
