Can a patient with ongoing chest pain undergo dialysis?

Management of Patients with Ongoing Chest Pain During Dialysis

In patients who experience acute unremitting chest pain while undergoing dialysis, immediate transfer by Emergency Medical Services (EMS) to an acute care setting is recommended, and dialysis should not be continued until the cause of chest pain is identified and addressed. 1

Assessment and Management Algorithm

Step 1: Immediate Response to Chest Pain During Dialysis

• Immediately stop dialysis when a patient reports chest pain
• Perform rapid assessment:
  • Obtain vital signs (blood pressure, heart rate, oxygen saturation)
  • Perform 12-lead ECG immediately
  • Assess for signs of hemodynamic instability

Step 2: Transfer Decision

• For unremitting chest pain: Arrange immediate EMS transfer to an acute care setting 1, 2
• For mild, transient pain that resolves quickly: Consider completing dialysis only if:
  • ECG shows no acute changes
  • Patient becomes completely asymptomatic
  • Vital signs remain stable
  • Close monitoring is available

Clinical Considerations

High-Risk Features Requiring Immediate Transfer

• Persistent chest pain despite initial interventions
• ECG changes suggestive of ischemia
• Hypotension during dialysis (may induce myocardial ischemia) 2
• Signs of pericarditis or pericardial effusion (may progress to tamponade) 3
• Symptoms of heart failure (occurs in up to 36.5% of patients with advanced kidney disease presenting with chest pain) 4

Common Causes of Chest Pain in Dialysis Patients

1. Cardiovascular causes (require immediate evaluation):

   • Acute coronary syndrome (most common severe cause, occurring in 2-5% of dialysis sessions) 2
   • Pericarditis (may present atypically in ESRD patients) 3
   • Arrhythmias induced by electrolyte shifts

2. Dialysis-specific causes (may allow continuation of dialysis if stable):

   • First-use syndrome (hypersensitivity reaction to dialysis membranes) 5
   • Metastatic pulmonary calcification (consider in patients with abnormal chest imaging) 6

Important Caveats

• Dialysis patients have higher baseline cardiovascular risk and worse outcomes (40.2% rate of MI, heart failure, or death at 30 days) when presenting with chest pain 4
• Standard cardiac biomarkers may be elevated in dialysis patients even without acute coronary syndromes, complicating diagnosis 7
• Patients on dialysis with chest pain should undergo the same thorough evaluation as non-dialysis patients, despite diagnostic challenges 2

Follow-up After Acute Episode

• After acute evaluation and stabilization, consider:
  • Stress testing to evaluate for ischemia
  • Echocardiography if pericardial disease is suspected
  • Adjustment of dialysis prescription if hypotension was a trigger
  • Review of calcium-phosphorus product if metastatic calcification is suspected

Remember that dialysis patients with chest pain have significantly higher morbidity and mortality compared to the general population, warranting a low threshold for transfer to an acute care setting rather than continuing dialysis during active chest pain.