Hemodialysis Management in Hemorrhagic Stroke Patients
Direct Answer
Hemodialysis should be continued in patients with hemorrhagic stroke who are already on chronic dialysis, but intermittent hemodialysis (IHD) is strongly preferred over continuous renal replacement therapy (CRRT), as CRRT is associated with significantly increased mortality (HR 1.28-1.32) even after controlling for illness severity. 1
Key Management Principles
Dialysis Modality Selection
Continue intermittent hemodialysis (IHD) rather than switching to peritoneal dialysis (PD) after hemorrhagic stroke onset, as PD is associated with dramatically worse outcomes (75% mortality vs 12.5% mortality with continued IHD). 2
Avoid CRRT when possible in the acute stroke setting, as it carries 28-32% increased mortality risk compared to IHD, even in ICU patients after controlling for common risk factors. 1
The only potential exception for CRRT consideration would be severe hemodynamic instability where IHD cannot be safely performed, though this still carries substantial risk. 1
Dialysis Prescription Modifications
Implement specific technical adjustments to minimize cerebral complications: 3
Use cooled dialysate to improve hemodynamic stability and potentially protect against dialysis-induced brain injury. 4, 3
Start blood flow slowly and increase gradually to avoid rapid osmotic shifts that can worsen cerebral edema. 3
Implement gentle fluid removal to prevent excessive ultrafiltration that may reduce systemic arterial blood pressure and exacerbate cerebral ischemia. 3
Avoid rapid urea reduction, as osmotic shifts from acute urea clearance can increase intracranial pressure and brain water content. 3
Critical Contraindications
Hemodilution strategies are absolutely contraindicated in hemorrhagic stroke patients, as intentional hemodilution does not reduce mortality or improve functional outcomes and may worsen bleeding risk (Class III, Level of Evidence A). 4, 5
Anticoagulation Management
Minimize or eliminate heparin use during hemodialysis sessions when possible, as uremic patients already have platelet dysfunction and increased bleeding risk. 6
Antiplatelet agents should be withheld in hemorrhagic stroke, as they are only recommended for ischemic stroke and should be carefully considered only with strong indication in hemorrhagic cases. 4
For patients with atrial fibrillation requiring anticoagulation, there is no clear evidence supporting warfarin or NOACs in dialysis patients with hemorrhagic stroke, and controlled studies are lacking. 4
Prognostic Factors
Poor prognostic indicators include: 2
- Lower hemoglobin levels at presentation
- Switching from hemodialysis to peritoneal dialysis after stroke onset (75% mortality)
- Need for surgical intervention (100% mortality in one series)
- Brainstem location of hemorrhage
Overall mortality for hemorrhagic stroke in dialysis patients is 44%, with death typically occurring within 15±13 days of onset. 2
Fluid Management
Maintain euvolemia with isotonic solutions (0.9% normal saline) rather than hypotonic solutions, as hypotonic fluids can exacerbate cerebral edema. 4
Volume expansion strategies without hemodilution are not recommended (Class III, Level of Evidence A). 4
Blood Pressure Management
Target blood pressure <130/80 mmHg in patients with previous stroke and chronic kidney disease, though intensive BP control may be deleterious specifically in dialysis patients. 4
Monitor for post-dialytic drops in systolic blood pressure up to 30 mmHg, which are associated with better survival, but greater decreases increase mortality. 4
Common Pitfalls to Avoid
- Do not switch to peritoneal dialysis after hemorrhagic stroke onset, as this dramatically worsens outcomes. 2
- Do not use CRRT routinely assuming it is "gentler"—the data show worse mortality. 1
- Do not pursue surgical intervention unless absolutely necessary, as outcomes are particularly poor. 2
- Do not implement hemodilution protocols despite theoretical benefits for cerebral perfusion. 4, 5