From the Guidelines
When dialyzing an ESRD patient during an NSTEMI, collaboration between nephrology and cardiology teams is crucial to consider volume status, electrolyte disturbances, and bleeding potential, and dialysis prescriptions should be adjusted to maximize benefits while reducing the risk of hypotension. The management of such patients requires careful consideration of their unique needs, balancing the necessity of renal replacement therapy with the risk of exacerbating cardiac ischemia.
Key Considerations
- Volume status and electrolyte disturbances should be carefully managed to avoid complications 1.
- Bleeding potential is a significant concern, and the use of antithrombotic and antiplatelet agents should be carefully considered 1.
- The use of aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and thrombolytic therapy may be beneficial, although controlled trials in dialysis patients are lacking 1.
- Abciximab and tirofiban (glycoprotein platelet IIb/IIIa inhibitors) may be considered as adjunctive therapy in ACS in dialysis patients, with careful attention to dosing and bleeding risk 1.
Dialysis Management
- Dialysis prescriptions should be adjusted to minimize the risk of hypotension, which can worsen cardiac ischemia 1.
- The choice of dialysis modality, intensity, and frequency should be individualized based on the patient's clinical status and needs.
- Close monitoring of the patient's hemodynamic status, electrolytes, and cardiac function is essential during dialysis 1.
From the Research
Considerations for Dialyzing an ESRD Patient During an NSTEMI
- ESRD patients are at a higher risk of cardiovascular events and hospitalization rates compared to those with normal renal function 2
- These patients may experience significant complications associated with loss of renal function and dialysis, including cardiopulmonary, neurologic, infectious disease, vascular, and access site complications 2
- When managing NSTEMI in ESRD patients, it is essential to consider the patient's renal physiology and the potential complications that may arise 2, 3
- Percutaneous coronary intervention (PCI) treatment has been shown to improve outcomes after acute myocardial infarction (AMI) in patients with ESRD and NSTEMI 4, 5
- A study found that PCI treatment during hospitalization was associated with reduced 1-year major adverse cardiac events (MACE) in patients with ESRD and NSTEMI 4
- Another study found that patients with chronic heart failure (HF) and ESRD who underwent PCI for NSTEMI had lower in-hospital mortality compared to those who received medical management only 5
Key Complications to Consider
- Cardiopulmonary complications, such as pericarditis, pericardial effusion/tamponade, acute coronary syndrome, and pulmonary edema 2
- Neurologic complications, such as uremic encephalopathy and cerebrovascular pathology 2
- Infectious disease complications, including access site infections and metastatic infections 2
- Vascular complications, such as bleeding, aneurysm/pseudoaneurysm, thrombosis/stenosis, and arterial steal syndrome 2
Management Strategies
- Focused history and physical examination are essential in evaluating and managing ESRD patients with NSTEMI 2
- Consideration of renal physiology and potential complications is crucial in managing these patients 2, 3
- PCI treatment may be beneficial in reducing MACE and improving outcomes in patients with ESRD and NSTEMI 4, 5
- Medical management, including anti-anginal, anticoagulant, and antiplatelet therapies, should be tailored to the individual patient's risk assessment 6