Safety analysis of intermittent hemodialysis in patients with continuous flow left ventricular assist devices

Abstract

Dialysis centers adopt a cautious approach when it comes to performing intermittent hemodialysis (HD) on patients with continuous flow (CF) left ventricular assist devices (LVADs) because of the potential for volume flux-related complications and absence of pulsatile blood pressure for monitoring. Many patients have to remain hospitalized because of the inability of the dialysis centers to accept them for outpatient dialysis. In this study, the effect of HD was observed in such patients. Between June 2009 and October 2012, 139 patients received LVADs, of which 10 patients (7%) required intermittent HD postoperatively. The mean age of the patients was 53 ± 14 years and 90% were men. A total of 281 dialysis sessions were administered amounting to 1025 hours of dialysis. The mean systolic blood pressure monitored with Doppler device was 97 ± 18 mmHg. Dialysis durations averaged 218 ± 18 minutes. Mean blood flow rate was 334 ± 38 cc/min, and 2.6 ± 1.1 L was ultrafiltrated during each session. Only 15 (5.3%) sessions were interrupted or terminated in six patients. The reasons for termination were symptomatic hypotension--6 (2.1%), asymptomatic hypotension--3 (1%), ventricular tachycardia--1 (0.36%), dialysis machine malfunction--2 (0.7%), low phosphorus--2 (0.7%), and abdominal cramps--1 (0.36%). Volume expansion was necessary on three occasions. Low-flow device alarms were registered during two (0.71%) sessions. The results showed no serious adverse effects or deaths.

Left ventricular assist devices: a kidney’s perspective

“…In a recent Dutch study, 11 % of patients required post-surgical continuous venovenous hemofiltration [64], but this number may even reach 33 % [45, 97, 113]. Fortunately, the majority of patients recover from AKI and RRT can in many cases be discontinued after about 1 month [114]. …”

“…Currently, cf-LVADs are volume-sensitive and can malfunction due to intravascular fluid flux inherent to HD [114]. Reduced blood volume as well as increased pump speed can create a so-called suction event in which the left atrium and ventricle collapse [114, 117].…”

“…Currently, cf-LVADs are volume-sensitive and can malfunction due to intravascular fluid flux inherent to HD [114]. Reduced blood volume as well as increased pump speed can create a so-called suction event in which the left atrium and ventricle collapse [114, 117]. Changes in pump speed due to volume sensitivity during HD can also induce thrombosis (reduced speed) or hemolysis (increased speed) [114, 117].…”

“…Reduced blood volume as well as increased pump speed can create a so-called suction event in which the left atrium and ventricle collapse [114, 117]. Changes in pump speed due to volume sensitivity during HD can also induce thrombosis (reduced speed) or hemolysis (increased speed) [114, 117]. Although challenging and not without risks, HD can be given to LVAD patients safely under specialized supervision.…”

Implantable Ventricular Assist Device Use and Outcomes in People With End‐Stage Renal Disease

“…Further, primary and post‐cardiotomy mechanical circulatory support were not distinguished in that report. Other publications on VADs in ESRD are limited to case reports and small case series 31, 32. Arteriovenous hemodialysis accesses, which divert a significant portion of the cardiac output from systemic perfusion and have been implicated in high‐output HF, have been a cause for concern, both in terms of whether maturation would occur for arteriovenous fistulas, and whether systemic perfusion would remain adequate 33, 34.…”