After 1 to 2 hours of Dialysis, I start discomfort in Heart then throbbing headache and then becoming Breathlessness

Hello Dr. Agar,
I am a Dialysis patient from Hyderabad city (India) and frequently read the Blog maintained by Mr.Kamal Shah. I know him personally also and meet him in patient get together’s occasionally.
While reading his posts, I came to know the about HomeDialysis website and felt very grateful to see your website and the way you are supporting to the patients all over world.

Sir, coming to my question, hereby I want to mention my Case history very briefly before putting my question.

I have diagnosed CKD in 2007 with some residual kidney function, ESRD (stage-5) started on Hemo dialysis from Feb/2008. Then in Aug/2008 I had Kidney Transplant (Live Donor-Paternal Aunt about 58years age then).
But the Graft failed (the creatinine used to increase month by month)and again started on Hemodialysis from May/2010 onwards.
I got HCV+ in year 2009 (it was diagnosed after the transplant).
Recent Viral load (HCV RNA PCR-Qty) is 55000copies, GenoType-1a,
My GI Endoscope shows Grade-1/2 Varices and iron overload(Tested in 2010)
Recently I got tested for Liver Fibros scan in mid 2016, it shows some LIVER fibrosis and the Kpa score is also higher side than the normal limits.
In 2015 & 2016 I had very high Hypertension (always near or above 160/100) even after taking 5 types of BP medications. Now the B.P is in control less tha 115/70 - 140/90.

My actual problem:
My actual problem is During Dialysis after 1to 2 hours of Dialysis, I start discomfort in Heart then throbbing headache and then becoming Breathlessness also associated with cool/sweat in arms and lower portion of the Legs. By the end of the 3rd hour I can’t bear anymore and feel like passing away If I still continue on Dialysis. All this is only at a Pump speed of 200ml/min. If the technician keeps the pump at more speed then the symptoms are induced even earlier than the duration I mentioned.
My Doctor sent me to Cardiac evaluation. The Reports like ECG, 2D-ECHO also Angio.
Ecg & 2D-ECHO: Concentric LVH+, Mild MR, Mild TR, Mild PAH, EF:64%
Normal LV Systolic Function, Grade-II LV diastolic function, No pericardial Effusion/Clot.
Angio: Coronay arteries are normal.
On the other side, My LFT reports are as below.
SGPT: 73(Normal:10-40), SGOT:48(15-40), Alkaline phospate:110(53-128)
Total Protein: 7.6, Albumin: 3.1
After reviewing all these reports, My Doctors saying the symptoms are not because of Cardiac issues.
Can you please advise something?
Because of the severe symptoms, I can’t complete the 4hours on dialysis and also can’t run the pump more than 200ml/min speed and leaving me with inadequate Dialysis.
Also I want to mention one thing here that “is the Low ALBUMIN can cause these symptoms”? My doubt is the low Albumin which may be the reason for Low oncoitic pressure, i.e. unable to move the water from other compartments to blood. Because of this reason, the Blood Volume is getting low and not able to maintain the circulation till the end organs?
I request you to please analyze my issue in your free time and come back with your answer please.
Thank you,
Best regards,

Hyderabad, INDIA.

Ading to the Previous post, I want to give some more information.
In my last Dialysis session I kept the U.F is only 800ml(time: 3and half hours). But still the above mentioned symptoms started after 2Hours (then I reduced the pump to 170ml/min) and I had to stop the Dialysis by a total time of 2 hours 50minutes.

First I develop heavy ness in Heart, then I feel light discomfort and difficulty for breathing. after a little while, frequent yawnings and then severe headache. This is horribly troubling me.

Hope you analyze my symptoms and come back with some advice for further Diagnosis.

Thank you Doctor.

Best regards,

Hyderabad, INDIA.

Dear Jogalamurali
I am so sorry to hear the trouble you are having and thank you for the effort you have put in to resolve it. It is also a rather strange set of symptoms and circumstances. One thing you haven’t said is the type/model of dialyser you are using and if you use a new set of lines and dialyser for each treatment or are reusing. Your question re albumin seems unlikely at an albumin of 31 (in your units, 3.1) … while a little low, it is not low enough to be likely to cause symptomatic dialysis, like you are having. If I were looking into this problem, it might be of interest, if it is feasible to do so, to draw blood before and at the end of your treatment, to know if there are any electrolyte issues, and what your urea reduction ratio might be, though it IS difficult to put a finger on what might be causing the problem. In addition, I trust you will understand that I cannot be your advisor nor your diagnostician via the internet … only your own nephrology team can be that, but it seems odd that you are on so many anti-hypertensive drugs … I would discuss this with your team to work out if some of these are causing your BP to fall - yawning is a bit of a clue, here - and if some of them need to be withheld or ceased. I am afraid I can’t be of much additional help, otherwise.

Dear Doctor,

Thank you very much for your answer,
I felt very happy and delighted to see your reply.

I would like to put some more information based on the questions raised, below this, point by point.

Type/model of Dialyser:
Here, we follow the standard practice of using F-6 Dialyser and reusing it for 4-6 times. However, the blood lines are not re-used and new tubing’s set is being used for every session.

Low Albumin issue:
Thank you very much for the clarification provided about my doubt regarding Low Albumin. Also as a trial on my side, in my last dialysis session, I kept the UF only just 800ml (the UFR=228ml/Hr) which is very normal but still the symptoms started troubling which I mentioned in my 2nd post. This means it is not the Low Albumin which is causing all this (perhaps).

To study the electrolyte issues: (for testing blood before and at the end), May you please suggest what all the tests to be carried? Example: Na, Cl, K and Blood Urea (before & after) or you advice any other thing also to be tested (Like: Magnesium, Calcium etc.)? As you mentioned, since I am away from you and you can’t physically examine me, though it is difficult to diagnose may be your valuable guidance may strike some direction to my Doctors here which can save my life for some time.

Now coming to the anti-hypertensive drugs:
presently I am on the below hypertensive and cardiac drugs:

  1. Nicardia Retard - 20mg (3times a day 9AM-3PM-10PM) C.C.B
  2. Nebistar – 5mg (2times a day 10AM&10PM) Beta blocker
    (Earlier I was on Metaprolol-50mg (OD). From jan/2017, changed to Nebivolol -5mg (BD) by a Senior Cardio-Electro physician)
  3. Minipress XL -5mg (2times a day 10AM&10PM)
  4. Flavadon MR (2times a day 9AM&9PM)
  5. Olmezest – 20mg (OD @2PM) (This drug started from past 4 months)
  6. Lonitab (Minoxidil) – 2.5mg (OD @2PM) (This drug started from past 3 months -My Blood Pressure came to a better control after starting this drug.

(I am also taking Shelcal CT, Nephrocaps, Revlamer 800mg, which are vitamin supplements and Phospate binder)

Just to brief you about my blood pressures, at the starting of the Dialysis in generally the B.P is less than 125/80. And it continues to be 5 points plus/minus for first 2 hours (till I get those symptoms). Once I feel discomfort in the heart and breathlessness a little, the B.P will increase 15-20 points every 30 minutes. And by the time when I feel heavy headache, the B.P would be >170/100. Few months back (when the drug Lonitab & Flavadon MR was not taking) the B.P was even up to 210/120.
My point here is – at the time of getting frequent yawnings – my Pressures are quite higher than usual. (Here in my Dialysis center, the B.P. is recorded every 15minutes by the Monitor). So I can say and make sure that the Yawning is not because of lowered pressures.
If you don’t mind and If am not troubling you, I request you to spend some of your valuable time to analyze the below issues and help in my Diagnosis:

  1. Yawning…Is it because of less Oxyzen/blood to Brain?
  2. Any suspect that are these symptoms are because of LVH?
  3. Any excess hormones production during dialysis causing vascular constriction and thereby over load on Heart. As I mentioned, My Blood pressure bounces after 2 Hours of Dialysis and it comes to near normal after just 10-20 minutes of stopping the Dialysis.

Thank you very much Doctor. Your valuable suggestions will definitely help my Diagnosis and provide treatment.

Best regards,

Hyderabad, INDIA.

Hi Muraleedhara,

Are you being treated at the same hospital every time? If so try changing it this might be machine issue causing trouble. As Dr. Agar said taking samples before and after dialysis for further testing can also potentially answer many questions. Hope you find it helpful.

Dear Jogalamurali

While I CANNOT act as your quasi-physician - either ethically, morally, or safely … I have not met you, I have not examined you, and I am not in any legal sense your physician - and I am anxious NOT to be placed in a position where anything I say might be taken as having direct application to you and your circumstances, I can make some general observations about individual problems that may or may not apply in any specific case.

It is on this basis and this basis alone that I have worked for a decade or more for HDC to try to point people in possible directions that may help them … always aware that what I say may NOT apply directly to the person seeking advice. I think you are asking me to sail pretty close to the wind, here … so the following observation is given as a GENERAL comment and MAY NOT apply to you

You describe ‘reuse’ … and there ARE symptoms associated with improperly re-processed dialysers that I wonder could possibly apply here. Upadhyay, Sosa, and Jaber very nicely describe many of the the issues with re-use in a now rather old (but good) paper in CJASN … “Single-Use versus Reusable Dialyzers: The Known Unknowns”.

The most common chemical agent used now-a-days to re-process dialysers is peracetic acid = likely but not necessarily the case in your re-use practice - and as they note … “peracetic acid can be potentially destructive to mucous membranes, especially of the respiratory tract, as well as to the skin and eyes. Inhalation may result in inflammation and edema of the larynx and bronchi, chemical pneumonitis, and even pulmonary edema. Symptoms of exposure include burning sensation, throat discomfort, cough, wheezing, dyspnea, headache, and nausea”. This has also been associated with hypertension during dialysis.

Another re-use chemical (now less used) is formaldehyde where the “accidental intravenous exposure to this formaldehyde can result in hypotension, cardiovascular collapse, lactic acidosis, respiratory failure, haemolysis with cold agglutinins and anti-Nform antibody formation + a Coombs-positive reaction”.

At least some of these responses are similar to the descriptions you give. This is NOT to say this is the reason for your problem, but one rather simple way to decide might be to use a new dialyser each run for a few runs rather than using a re-constituted dialyser … and see if the symptoms stop.

If this doesn’t have any demonstrable effect, then as you appear to be one of the small percentage of dialysis patients whose BP rises during dialysis, you might talk with your nephrologist about the possibility of running your dialysate sodium lower … maybe @ 137 or 135.

These a general observations only … otherwise, all I can suggest is that you work through with your nephrologist to eliminate as many things as you can.

I doubt, at this distance, that I can do more than pass the comments/suggestions I have. That is the best (and all) that I can do. I appreciate the time you have given to the details of your case, but as I have not met you, not act as your physician, I am loathe to be more specific or didactic that this.

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