From the Guidelines
Thrombolysis can be performed in patients with End-Stage Renal Disease (ESRD) undergoing dialysis, but it is recommended that emergent PCI be the preferred treatment if available due to the potential increased hemorrhagic risk associated with thrombolytic therapy. The decision to perform thrombolysis in these patients should be individualized, taking into account their specific clinical situation and weighing the potential benefits against the risks 1. For patients with ST-segment elevation MI, acute reperfusion therapy is recommended, similar to the nondialysis population 1.
When considering thrombolysis in dialysis patients, it is essential to closely monitor coagulation parameters and consider the timing relative to dialysis sessions to minimize bleeding complications. Patients on hemodialysis often have uremic platelet dysfunction and may be on anticoagulants for dialysis access, further increasing bleeding risk. Additionally, these patients frequently have comorbidities like hypertension and diabetes that may affect thrombolysis outcomes.
The healthcare team should be prepared to manage potential bleeding complications with appropriate blood products and reversal strategies if needed. Despite the increased risks, thrombolysis should not be automatically withheld from dialysis patients who might benefit from this potentially life-saving therapy. It is crucial to note that the choice of anticoagulant may be influenced by factors such as drug availability, cost, patient liver function, and clinician experience 1.
Key considerations for thrombolysis in dialysis patients include:
- Close monitoring of coagulation parameters
- Timing of thrombolysis relative to dialysis sessions
- Management of potential bleeding complications
- Individualized decision-making based on patient-specific factors
- Preference for emergent PCI if available due to increased hemorrhagic risk associated with thrombolytic therapy 1.
From the Research
Thrombolysis in Patients with End-Stage Renal Disease (ESRD) Undergoing Dialysis
- Thrombolysis can be performed in patients with ESRD undergoing dialysis, but the decision to do so is complex and depends on various factors, including the patient's overall health, the type of dialysis, and the presence of other medical conditions 2.
- A survey of stroke experts found that most favored the use of intravenous recombinant tissue-type plasminogen (rt-PA) for hemodialysis patients with acute ischemic stroke, despite the acknowledged absence of data and concerns about bleeding risk 2.
- Percutaneous declotting is generally preferred over surgical thrombectomy for arteriovenous (AV) access thrombosis in hemodialysis patients, and various percutaneous approaches can be employed, including the lyse-and-wait technique, thromboaspiration, and mechanical thrombectomy device 3.
- The use of antithrombotic medications in ESRD patients is a double-edged sword, as they are necessary to prevent thromboembolic events, but also increase the risk of bleeding 4.
- ESRD patients have an increased risk of venous and arterial thrombosis, and the occurrence of thrombosis prior to dialysis is associated with an increased mortality risk 5.
- The efficacy and safety of tenecteplase versus alteplase for thrombolysis of acute ischemic stroke have been compared in several studies, and the results suggest that tenecteplase may be a potential substitute for alteplase in certain patients 6.
Considerations for Thrombolysis in ESRD Patients
- The decision to perform thrombolysis in ESRD patients should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history 2, 4, 5.
- The type of dialysis and the presence of other medical conditions, such as atrial fibrillation or malignancy, should also be considered when deciding whether to perform thrombolysis in ESRD patients 2, 4, 5.
- The use of antithrombotic medications and the risk of bleeding should be carefully weighed against the potential benefits of thrombolysis in ESRD patients 4, 5.