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  Thursday, 18 April 2013
  5 Replies
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I have a patient who has severe cramping on and even off dialysis. Have tried IV Levocarnitine, 50% dextrose injections, Vit E supplements, lowering blood and dialysate flows, manageable inter-dailytic weight gain. He does not have intra-dialytic hypotension. Nothing has worked so far (2 weeks). Have not tried quinine fearing the toxicity and hypertonic saline (only 3% is available here). Any suggestions?
11 years ago
My first concern would be that this is a manifestation of ECF volume depletion, or impaired vascular refilling.There can be significant ECF volume contraction, without hypotension. If you have access to blood volume monitoring, that will give you the needed insight into vascular refilling. If not, I would suggest aiming for a dry weight, at least 1 kg above the current dry weight and see the impact on the cramps. If they improve, but persist, I would go even higher. What dialysate [Na] are you using? You might also see improvement by ramping the dialysate [Na], starting with a [Na] 5-10 mmols/L above your current [Na] and ending with a [Na] 5-10 mmol/L lower. You don't want to send your patient home with a seum [Na] higher than that with which he comes in.If all this fails, I would not be afraid to use quinine 200 mgmspre dialysis, just follow the CBC. Magnesium is also helpful for the cramps at home. Good luck, let us know the outcome.
11 years ago
Thanks Dr.Goldstein for your valuable inputs. We do not have blood volume monitoring here. I was reluctant to increase his dry weight because he is already edematous and serum albumin is an acceptable 3.9. Anyway I think I will still increase his dry weight now and see if it helps.Concurrently I will also try the sodium profiling and then quinine. What is your opinion on using 3% NaCl? Other than blood volume monitoring and clinical examination, what else can one do to accurately assess the ECF volume?
11 years ago
Hi, edema may also be due to local causes (eg phlebitis, retroperitoneal obstruction), tensor bandages to the hips will promote vascular refilling.If you use tensors, tell the patient to keep them on until they go to bed, otherwise, fluid will redistribute in the upright posture, and symptoms may develop. If the RV function and pulmonary artery pressure are normal, the CVP may reflect the ECF volume, however, it may be misleading in the presence of pulmonary hypertension or impaired RV function or RV filling (eg tamponade or diastolic dysfunction).when right sided pressures do not reflect what the LV is seeing. If you are asking about the use of 3% saline to expand the ECF volume at the expense of the ICF, that may be useful early in the dialysis, but you must take care to send the patient home with their usual post dialysis [Na], or there will be increased interdialytic weight gain, compounding the problem (unless your target DW is too low.You can calculate the change in Blood Volume from beginning to end of the treatment by measuring the Hct at the onset and end of dialysis, using the formula % Change in blood volume = (initial Hct/ final Hct) - 1. Patients usually tolerate a fall in BV of 10% quite well, whereas > 15% often causes symptoms. Let us know the outcome. Cheers. Marc
11 years ago
Thanks again Dr.Goldstein. I will try a few of the things you have suggested and keep you posted on the outcome.
11 years ago
We increased the dry weight by a kilo and started the sodium modelling. Cramps have significantly reduced. Will see how he progresses over the next few weeks and start Quinine if required. Thanks again.
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