What is the risk of intracerebral hemorrhage in patients undergoing dialysis (renal replacement therapy)?

From the Guidelines

Patients on dialysis have a significantly increased risk of intracerebral hemorrhage, with warfarin use associated with a possibly increased risk of intracranial hemorrhage (HR, 1.93; 95% CI, 0.93-4.00) 1. The risk of intracerebral hemorrhage in patients undergoing dialysis is a critical concern due to the high morbidity and mortality associated with this complication. Several factors contribute to this increased risk, including uremic platelet dysfunction, heparin use during dialysis, and blood pressure fluctuations.

• The use of warfarin in patients with atrial fibrillation on dialysis has been associated with an increased risk of major bleeding, including intracranial hemorrhage, without a clear benefit in reducing the risk of stroke or systemic embolism 1.
• Novel oral anticoagulants (NOACs) may have a more favorable safety and efficacy profile compared to warfarin in patients with chronic kidney disease, but their use in patients on dialysis is still being studied, with ongoing trials aiming to determine their safety and efficacy in this population 1.
• The management of intracerebral hemorrhage in dialysis patients requires immediate medical attention, including temporary suspension of dialysis, urgent neurosurgical consultation, and reversal of anticoagulation, as well as careful blood pressure control and consideration of switching to regional citrate anticoagulation or heparin-free dialysis to minimize bleeding risk.
• Long-term management includes strict blood pressure control, careful anticoagulation monitoring, and consideration of switching from conventional heparin to citrate or low molecular weight heparin for future dialysis sessions to reduce recurrence risk.
• The decision to use anticoagulation therapy in patients with atrial fibrillation on dialysis should be individualized, taking into account the patient's risk of stroke and bleeding, as well as their renal function and other comorbidities, with close monitoring of renal function and bleeding risk factors 1.

From the Research

Risk of Intracerebral Hemorrhage in Patients Undergoing Dialysis

The risk of intracerebral hemorrhage in patients undergoing dialysis is a significant concern, with several studies investigating the incidence, management, and outcomes of this condition.

• The incidence of intracerebral hemorrhage in hemodialysis patients is higher than in the general population, with a study finding that 6% of patients in one phase of the study experienced intracerebral hemorrhage 2.
• Another study found that the incidence of cerebral hemorrhage has risen with the increase in the number of hemodialysis patients, with 64 patients treated over an 18-year period 3.
• The use of anticoagulants, such as aspirin and heparin, has been associated with an increased risk of bleeding in hemodialysis patients, with one study finding that minimizing aspirin use in patients with severe hypertension reduced intracerebral bleeding 2.
• Nafamostat mesilate, a serine protease inhibitor, has been shown to be effective in preventing further bleeding in hemodialysis patients with intracerebral hemorrhage, with a study finding that it had a similar profile of anti-coagulative activity to heparin 4.

Factors Associated with Poor Outcomes

Several factors have been associated with poor outcomes in hemodialysis patients with intracerebral hemorrhage, including:

• Mixed hemorrhage, hematomas greater than 61 ml, and age 70 and older 3.
• Bedridden status, with one study finding that patients who were bedridden had a significantly poorer prognosis than those who were not 5.
• Infections, such as sepsis and pneumonia, which were found to be a major cause of death in hemodialysis patients with intracerebral hemorrhage 5.

Management and Treatment

The management and treatment of intracerebral hemorrhage in hemodialysis patients is a complex issue, with several studies investigating the effectiveness of different approaches.

• One study found that urgent stabilization of cardiorespiratory variables and treatment of intracranial complications was essential in the initial management of intracerebral hemorrhage 6.
• The use of recombinant factor VIIa (rFVIIa) has been investigated as a potential treatment for intracerebral hemorrhage, but its effectiveness has not been substantiated by large phase III studies 6.
• The management of patients with intracerebral hemorrhage in a specialist neurointensive care unit has been shown to be associated with improved outcomes 6.