Can a hemodialysis session be performed on a patient with Chronic Kidney Disease (CKD) who has tachycardia (elevated pulse rate) and normal blood pressure?

Can Hemodialysis Be Performed with Pulse Rate 138 bpm and BP 120/80?

Yes, hemodialysis can be performed in this patient, but the tachycardia requires immediate investigation and continuous cardiac monitoring during the session, as the elevated heart rate (138 bpm) represents a significant mortality risk factor even though the blood pressure is acceptable. 1

Immediate Pre-Dialysis Assessment Required

Before proceeding with dialysis, you must:

• Obtain a 12-lead ECG immediately to identify the underlying rhythm (atrial fibrillation, sinus tachycardia, ventricular tachycardia, or other arrhythmia), as all dialysis patients with new or unexplained tachycardia require ECG evaluation 1
• Check electrolytes urgently (potassium, magnesium, calcium) as these are the primary triggers of life-threatening dysrhythmias in CKD patients, with hyperkalemia accounting for a substantial proportion of sudden cardiac deaths 1
• Assess volume status clinically to determine if the tachycardia represents compensatory response to volume overload or other hemodynamic stress 2
• Review medications for QT-prolonging agents or recent changes in beta-blockers, as dialysis can remove beta-blockers leading to rebound tachycardia 1

Blood Pressure Considerations

The BP of 120/80 mmHg is acceptable for proceeding with dialysis:

• This BP falls within safe parameters for hemodialysis initiation, as current guidelines recommend treating CKD patients when office BP is ≥140/90 mmHg, and targeting systolic BP to 130-139 mmHg range 2
• Pre-dialysis BP of 120/80 mmHg does not contraindicate dialysis, though post-dialytic drops in systolic BP of up to 30 mmHg are associated with higher survival, while greater decreases or any increase in systolic BP are related to increased mortality 2
• Standing BP measurement is mandatory before proceeding, as orthostatic hypotension may be masked by the sitting measurement and could predict intradialytic hemodynamic instability 3

The Tachycardia Problem: Why It Matters

Pre-hemodialysis pulse rate ≥80 bpm carries significantly increased 1-year mortality risk, making this patient's heart rate of 138 bpm particularly concerning 1, 4:

• Compromised myocardium from underlying coronary artery disease cannot tolerate the combined stress of rapid ultrafiltration and elevated heart rate, increasing risk of myocardial ischemia and arrhythmias 1
• Left ventricular hypertrophy (present in 80% of dialysis patients) further impairs diastolic filling when heart rate is elevated, contributing to hemodynamic instability 1
• Dynamic electrolyte fluctuations during dialysis create a dysrhythmogenic state that persists for 4-5 hours after dialysis, particularly dangerous in patients with underlying structural cardiac abnormalities 1
• Potentially life-threatening ventricular dysrhythmias occur in 29% of patients during 24-hour monitoring that includes the dialysis period, with atrial dysrhythmias in 10% and ventricular dysrhythmias in 76% of maintenance hemodialysis patients 1

Mandatory Monitoring During This Session

Continuous ECG monitoring is required throughout this dialysis session given the tachycardia, as recommended for hospitalized hemodialysis patients with severe electrolyte abnormalities, QT-prolonging medications, or known structural heart disease 1, 4:

• Cardiac arrest rate during hemodialysis is 7 events per 100,000 dialysis sessions, with 62% presenting as ventricular fibrillation/ventricular tachycardia, highlighting the importance of continuous monitoring in high-risk patients 1, 4
• Blood pressure measurements should be increased to every 15-30 minutes when tachycardia is present, rather than the standard hourly measurements 4, 3
• Ensure automatic external defibrillator availability, as it should be present in all outpatient hemodialysis clinics 4

Dialysis Prescription Modifications

Consider these adjustments to improve hemodynamic stability:

• Use cooler dialysate temperature (0.5°C below core body temperature) to improve vascular stability and reduce circulatory stress, as this approach reduces mean arterial pressure extrema point frequencies and may protect against dialysis-induced brain injury 2, 1
• Extend treatment time beyond the standard 3 hours if the patient has high interdialytic weight gain or requires aggressive ultrafiltration, as longer treatment times improve hemodynamic stability during HD 2
• Reduce ultrafiltration rate if possible to minimize hemodynamic stress, as the safety and tolerability of HD is dictated in part by the ultrafiltration rate 2
• Adjust dialysate composition to minimize electrolyte fluctuations rather than using IV supplementation, particularly for potassium and magnesium 1

Electrolyte Management Strategy

Maintain serum potassium between 3.5-4.5 mmol/L and magnesium above threshold levels to minimize risk of arrhythmias 1:

• Do not treat hypokalemia or hypocalcemia without checking and correcting magnesium first, as these will be refractory to replacement 1
• Never give IV magnesium supplementation during dialysis, as this can cause dangerous fluctuations 1
• Monitor electrolytes during dialysis and for 4-5 hours post-dialysis, as the dysrhythmogenic state persists well after the session ends 1

Common Pitfalls to Avoid

• Do not proceed without identifying the underlying rhythm, as ventricular tachycardia requires immediate cardioversion if hemodynamically unstable 1
• Do not assume the tachycardia will resolve with fluid removal alone, as multiple mechanisms beyond volume overload can cause elevated heart rate in dialysis patients 1
• Do not use sotalol if the patient has systolic dysfunction or heart failure, as it has been associated with pro-arrhythmia in ESRD patients 1
• Do not defer the dialysis session if the patient is volume overloaded, as the risks of uremia and volume overload may outweigh the tachycardia risk, but proceed with enhanced monitoring 2

Post-Dialysis Management

The patient requires close follow-up after this session:

• Repeat ECG post-dialysis to assess for rhythm changes and QTc interval 4
• Recheck electrolytes 4-5 hours post-dialysis, as arrhythmias often occur during this period due to ongoing electrolyte fluctuations 1
• Consider cardiology consultation if tachycardia persists or if ventricular arrhythmias are identified, as device therapy or antiarrhythmic medications may be indicated 1
• Evaluate for underlying causes including infection, anemia, thyroid dysfunction, or cardiac ischemia that may be driving the tachycardia 1