Myocardial Stunning

[Riki]

Can anyone tell me what that is, in English?  I tried to look it up, like my doctor told me to do, but I can't find anything that I understand.

Some back story.. for the last 5-6 months or so, at the end of my treatment, my bp drops like a stone.  More often than not, I'd say around 85% of the time, I have no symptoms, even though my systolic pressure can drop to 75 or lower.  The original thought was that my weight was going up and they were taking too much fluid off, so my dry weight went up, and it went up rather quickly, from 88.5kgs back in September to 95kg as of Friday.  It took me 2 years to get my weight down below 90kgs, so I could be taken off hold on the transplant list, and I'm afraid that the rapid rise of my dry weight because of my bp will put me back on hold again, and I've only been active since the beginning of January.  On Friday, one of my nephs told me that the bp drop could be caused by myocardial stunning.  He didn't explain what it was, but said that it had something to do with fluid transfer, and he told me to look it up.  I tried looking it up, but anything I found had a lot of technical terms that I just don't understand.  If I have to look up the words that describe what I'm looking up, well, I get even more confused. *L*

[PrimeTimer]

I don't know if this will help (and hopefully I posted the link correctly, sorry, not computer savvy) but I believe Dr. John Agar's article on "The Dialysis Waterfall" might help understand dialysis-stunning.

http://homedialysis.org/news-and-research/blog/27-dialysis-waterfall-forget-urea


My husband does home-hemo. Whenever we see his BP drop and continue to drop, I give him a small saline bolus but also slow down the UF Rate (fluid removal rate). If his BP continues to drop too much too quickly, then we take him off the machine rather than keep on giving him saline boluses and putting more fluid back on him. Whenever he is close to his dry weight or even under it, we don't take too much fluid off of him, only very little so that his BP won't crash and to avoid nausea and cramping. And if his BP is low at pre-treatment, then we go at slower rates for longer treatment time.
Hope this helps and that you will feel better. Sorry your doc didn't explain things to you, some docs just cannot seem to talk plainly to their patients while other docs are wonderful at communicating.

[noahvale]

*

[Riki]

Actually, no.. it didn't explain what it is..

[Hemodoc]

I wrote a few articles on this with Bill back in 2010.

http://www.billpeckham.com/from_the_sharp_end_of_the/2010/03/myocardial-stunning-is-common-in-dialysis-patients.html

Simply put, myocardial stunning, hybernation and ischemia are related conditions where the heart muscle loses adequate oxygenation and becomes dysfunctional from ischemia, or lack of blood flow. Stunning and hybernation are similar terms referring to lack of wall motion in the heart after low blood flow.

Low blood pressure is multifactorial in dialysis patients. Low blood pressure is one of the causes of low blood flow to the heart. Another cause is the low potassium bath that removes potassium in the artificial kidney. When the venous blood returns to the heart, the low potassium causes the blood vessels to tighten or vasoconstrict. This also,lowers blood flow to the heart.  Even with low ultrafiltration, blood flow to the heart is diminished in almost all dialysis patients, high ultrafiltration rates and low,potassium baths worsen the effect to the point many develop ischemia with slight damage to the heart that leads to,damage to,the heart muscles. Over time, this damage causes scarring which leads to dilation of the remaining heart muscle. The result is congestive heart failure which worsens fluid control. To combat poor fluid control, nephs use higher ultrafiltration rates and sodium profiling leading to worsening myocardial ischemia in a downward spiral difficult to combat.

[Riki]

Thank you.  I didn't know what ischemia was.. I just thought it weird that while reading through an explanation of something, and have to stop to look up a word in the explanation.. Also, not impressed that the doctor just told me to look it up.. then the other doctor comes along.. we have a short conversation...  he says "your bp is running low today."  I say, "yeah, it does every day."  He says, "you're feeling okay, though?  Not feeling faint or cramping?"  I say, "no, I'm good."  He says, "I wouldn't worry about it, then."  Then he waslks away.. huh?

[Hemodoc]

Thank you.  I didn't know what ischemia was.. I just thought it weird that while reading through an explanation of something, and have to stop to look up a word in the explanation.. Also, not impressed that the doctor just told me to look it up.. then the other doctor comes along.. we have a short conversation...  he says "your bp is running low today."  I say, "yeah, it does every day."  He says, "you're feeling okay, though?  Not feeling faint or cramping?"  I say, "no, I'm good."  He says, "I wouldn't worry about it, then."  Then he waslks away.. huh?

Once again, there are many reasons why the BP can run low, not all of which are dangerous. If your potassium runs high, that could lower BP as a vasodilator. Simple things to check are an EKG and if not completely normal, consider an echocardiogram. CHF is all too common in long term dialysis patients.

[Riki]

I've noticed, in the 24 years that I've been doing this, that my bp tends to go in stages... for a while, it'll be extremely high and need to be controlled with meds, then it'll drop into my shoes for a while... I don't feel any different either way, and trying to explain this to nurses who've only known me a few years, and doctors who've known me even less.. Well, it's frustrating.. when I was on PD, my bp was always low... since I've been on HD, it's been all over the place...

[Zach]

I wrote a few articles on this with Bill back in 2010.

http://www.billpeckham.com/from_the_sharp_end_of_the/2010/03/myocardial-stunning-is-common-in-dialysis-patients.html

Simply put, myocardial stunning, hybernation and ischemia are related conditions where the heart muscle loses adequate oxygenation and becomes dysfunctional from ischemia, or lack of blood flow. Stunning and hybernation are similar terms referring to lack of wall motion in the heart after low blood flow.

Low blood pressure is multifactorial in dialysis patients. Low blood pressure is one of the causes of low blood flow to the heart. Another cause is the low potassium bath that removes potassium in the artificial kidney. When the venous blood returns to the heart, the low potassium causes the blood vessels to tighten or vasoconstrict. This also,lowers blood flow to the heart.  Even with low ultrafiltration, blood flow to the heart is diminished in almost all dialysis patients, high ultrafiltration rates and low,potassium baths worsen the effect to the point many develop ischemia with slight damage to the heart that leads to,damage to,the heart muscles. Over time, this damage causes scarring which leads to dilation of the remaining heart muscle. The result is congestive heart failure which worsens fluid control. To combat poor fluid control, nephs use higher ultrafiltration rates and sodium profiling leading to worsening myocardial ischemia in a downward spiral difficult to combat.

Hello Hemodoc,

Is it true that lowering the dialysate temperature might provide help in this situation?

Regards,
--Zach

[Hemodoc]

Yes, there have been some articles on this for a few years with another one recently as well. For those of us on NxStage, being cold, cold, cold is part of the wonders of treatment. Some are now advocating setting your temp on the machine half a degree below your measured temp. This is apparently most protective of the brain during dialysis.

There is much more we need to research on optimal dialysis if only they would.

[PrimeTimer]

Yes, there have been some articles on this for a few years with another one recently as well. For those of us on NxStage, being cold, cold, cold is part of the wonders of treatment. Some are now advocating setting your temp on the machine half a degree below your measured temp. This is apparently most protective of the brain during dialysis.

There is much more we need to research on optimal dialysis if only they would.

Wow! Thanks for this info, Hemodoc, this definitely has my attention! Thanks, too for better explaining myocardial stunning. I didn't know that the temperature of dialysate is of such medical importance...just thought it had more to do with patient comfort (wanting to be warm) and not running the temp too hot or too cold in order to avoid getting alarms on the NxStage cycler. 

[Riki]

Yesterday, they set my machine at 35.5C, though I have no idea what they normally set it at, and except for one reading about half way through, my systolic stayed above 100 through the whole run.  I think we may actually be on to something here

[obsidianom]

Yes, there have been some articles on this for a few years with another one recently as well. For those of us on NxStage, being cold, cold, cold is part of the wonders of treatment. Some are now advocating setting your temp on the machine half a degree below your measured temp. This is apparently most protective of the brain during dialysis.

There is much more we need to research on optimal dialysis if only they would.

I posted this MONTHS ago . Everyone ignored me.   !!!!!!!!!!!!

 COOL IT ! -New Research on dialysate temperature
« on: September 30, 2014, 04:03:58 PM » Reply with quote Modify message 

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Medscape Medical News

Dialysate Cooling Reduces Hemodialysis-Induced Brain Injury

Diana Phillips
September 25, 2014

Using a cooled dialysate solution protects the brains of patients receiving hemodialysis from the progressive white matter injury to which they are otherwise vulnerable, results from a new study show.

To determine the effect that hemodialysis-associated circulatory stress has on brain white matter microstructure over time and to determine whether a dialysate temperature of 0.5°C below core body temperature mitigates the potential for damage, Mohamed T. Eldehni, MD, from the Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, United Kingdom, and colleagues conducted a randomized clinical trial on incident hemodialysis starting within 6 months.

Of 73 patients enrolled in the study, 37 were dialyzed with a dialysate temperature of 37°C and 36 were dialyzed with a solution cooled to 0.5°C below core body temperature. The final analysis included 19 well-matched patients in each group who had undergone diffusion tensor imaging at baseline and at 12-month follow-up.

In aggregate, patients in both groups exhibited a pattern of ischemic brain injury reflected by increased fractional anisotropy (FA) and reduced radial diffusivity (RD), the authors report in an article published online September 18 in the Journal of the American Society of Nephrology.

In the group dialyzed with the cooled solution, "[t]here were no statistically significant changes in FA, RD, or [axial diffusivity (AD)] between baseline and 12 months," the authors write. "However, the group that dialyzed at 37°C had increased FA at 12 months compared with baseline." In the latter group, the mean FA of the statistically significant voxels highlighted in the paired images increased from 0.432 at baseline to 0.452 at 12 months. Moreover, using the John Hopkins University atlas for white matter tracts, the authors "found statistically significant voxels in 18 of 20 regions represented by this atlas."

A voxel-wise analysis comparing the 2 groups at baseline and at 12 months showed no difference in FA at baseline but a significantly higher mean FA in the 37°C group than in the cooled group at 1 year, the authors state.

With respect to hemodynamic performance and brain white matter integrity, "Repeated measures [analysis of variance] showed that the group that dialyzed at 37°C had a significant increase in mean arterial pressure (MAP) extrema points frequencies at 1 year, whereas the intervention group did not," the authors write. "Furthermore, in a voxel-based analysis, the correlation between MAP extrema points frequency during HD on 1 hand and FA and RD on the other hand was examined using [tract-based spatial statistics]. Higher MAP extrema points frequencies were associated with higher FA." There was no correlation between the number of intradialytic hypotension episodes and FA, RD, or AD changes, they report.

The increased FA, decreased RD, and stable AD observed in the control patients appear to correlate with a higher frequency of change in peaks and troughs of MAP, the authors observe. "The pattern that we found in this study of increased FA and reduced RD is rather unexpected, because these changes have been described in acute ischemic stroke within <24 hours. The [magnetic resonance] imaging at baseline and follow-up was performed on a nondialysis day within <24 hours from the dialysis session, and therefore, it is plausible that our findings — indicating acute ischemia — are related to the previous dialysis session, which then was exacerbated over 1 year of [hemodialysis] treatment." This finding supports the hypothesis that patients receiving hemodialysis are susceptible to recurrent acute ischemic brain insults that result from hemodialysis-induced circulatory stress, which is similar to findings previously observed in the myocardium, they note.

The absence of changes in brain white matter FA, AD, or RD in the cooled solution group at 1 year, and the stability of the MAP extrema points frequencies during the same period, suggest that reducing the dialysate temperature "seems to have a significant effect on hemodynamic stability, organ perfusion, and end organ damage in this population, which is burdened with impaired hemodynamic regulatory functions," the authors write.

On the basis of these findings, the authors suggest this study "justifies additional larger-scale testing of dialysis-based interventions to reduce the burden of morbidity and mortality in [hemodialysis]."

The authors have disclosed no relevant financial relationships.
 
 
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My wife is the most important person in my life. Dialysis is an honor to do for her.
NxStage since June 2012 .
When not doing dialysis I am a physician ,for over 25 years now(not a nephrologist)

Any posting here should be used for informational purposes only . Talk to your own doctor about treatment decisions.

[PrimeTimer]

This is all very interesting! If my husband is too cold during dialysis to the point that he shivers, his BP rises. And I thought that so long as the machine doesn't alarm that the dialysate is too hot/too cold, that everything is fine. These reports make me wonder, tho. 

[Riki]

Well, it seems that setting the temp at 35.5C only worked once.  I seem to have gone back to the low bp during treatment, and needing to have extra fluids given at the end of treatment to bring it up again, still with no symptoms.  I'm at a loss as to what to try at this point.