Non-Occlusive Mesenteric Ischemia in Chronically Dialyzed Patients: A Disease with Multiple Risk Factors

Abstract

Background: Non-occlusive mesenteric ischemia (NOMI) can be a fatal complication in dialysis patients. Intradialytic hypotension is usually the precipitating factor. The occurrence of 16 cases in 5 years (1998–2002), compared with only 4 in previous years, led us to investigate other risk factors contributing to NOMI. A control group of stable hemodialysis patients was used for comparison. Results: 20 patients were studied: 17 diagnosed surgically, and 3 clinically. The mean age was 70.8 ± 1.8 years, and the male:female ratio 7:13. Nineteen patients were on hemodialysis. Clinically overt atherosclerosis was present in 17 patients. Preceding dialysis-associated hypotension was identified in all patients studied and access thrombosis in 6 patients. In all patients, abdominal pain was the presenting symptom. Initial abdominal examination was unimpressive in 16 patients. The hemoconcentration, leukocytosis and metabolic acidosis were the most prominent laboratory findings. 5/11 abdominal sonograms showed intestinal pathology. 2/3 angiographies were diagnostic. Three patients responded to early fluid challenge and did not require surgery. Pathology was related to the area of the superior mesenteric artery in all 15 patients operated. Twelve (60%) patients died from the event. The 1-year mortality rate was 17/20 patients (85%). Possible contributing factors, other than dialysis-associated hypotension, included: high-dose recombinant human erythropoietin (rhEPO) therapy (179 ± 35 vs. 116 ± 10 U/kg/week in the control group, p < 0.05); metastatic calcifications (abdominal aorta 14/14, aortic valve 11/18; medial calcification of mesenteric arteries in 2/11 pathology specimens); digoxin, and hypoalbuminemia. Conclusions: The increased incidence of NOMI in dialysis patients may be related to overly aggressive rhEPO therapy and the unsuspected presence of mesenteric arterial medial calcifications. Identification of patients at risk, prevention of intradialytic hypotension and a controlled increase in dry weight may help to reduce the incidence of NOMI in chronically dialyzed patients.

The Very Old on Hemodialysis: 8 Years' Experience in a Single Unit

“…Elderly patients are often prescribed shorter HDx treatment time as they weigh less, often have a lower interdialytic weight gain and their ultrafiltration requirements are lower. Despite this, dialysis-induced hypotension is more frequent in the elderly [18], and these events may compromise cerebral perfusion and cognitive function and cause episodes of nonocclusive mesenteric ischemia and ischemic optic neuropathy [19,20,21]. Just recently, Flythe et al [17] substantiated our findings by showing increased patient mortality (hazard ratio 1.34) in patients >65 years old when dialyzed for a shorter dialysis session length.…”

Cooling dialysate during in-center hemodialysis: Beneficial and deleterious effects

“…IDH is an independent risk factor for mortality in patients on hemodialysis [5,6] and may negatively affect their quality of life [7] . It is also associated with increased morbidity including frontal lobe atrophy [8] , myocardial injury [9] , and mesenteric ischemia [10] . Nephrologists employ various methods on dialysis to minimize IDH including sodium modeling, ultrafiltration profiling, addition of calcium or bicarbonate to the dialysate bath, and dialysate cooling.…”

Improvements in Pneumatosis Cystoides Intestinalis and Hepatic Portal Venous Gas with Conservative Therapy in a Patient on Maintenance Dialysis

“…States of a low cardiac output, a reduced circulating plasma volume, dehydration and hypotension can cause the peripheral mesenteric arteries to spasm, leading to noncontinuous segmental intestinal ischemia or necrosis. The risk of NOMI is particularly high in hemodialysis patients because of vascular calcification caused by Ca/P metabolism disorders or hypotension during hemodialysis (2,3). In this case, hypotension and other symptoms appeared during hemodialysis, which suggests that ultrafiltration may lead to spasms of the mesenteric artery, resulting in NOMI.…”

“…Generally, the presence of both PCI and HPVG is considered to be strongly suggestive of intestinal necrosis (1). Hemodialysis patients are at a particular risk of intestinal ischemia due to vascular calcification from either calcium (Ca)/phosphorus (P) metabolism disorders or hypotension during hemodialysis (2,3). Surgical treatment should be considered as there is a possibility of intestinal necrosis occurring when both PCI and HPVG are present (1).…”