ACUTE HYPERCAPNIC RESPIRATORY FAILURE FOLLOWING INITIATION OF HEMODIALYSIS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Patients receiving hemodialysis are prone to rapid changes in acid-base status with modern high-flux dialyzer membranes. These rarely consequential but may be problematic patients hypoventilation. We present a case of acute hypercapnic respiratory failure following initiation man oliguric kidney injury (AKI) and morbid obesity obstructive sleep apnea (OSA) hypoventilation syndrome (OHS). CASE PRESENTATION: A 75 y.o. CKD Stage 4 due hypertension diabetes was admitted for AKI. He had multiple comorbidities including obesity, OSA, OHS prior strokes. required progressive azotemia acidemia. baseline ABG this admission pH 7.35, pCO2 47 mmHg, pO2 132 mmHg on L/min NC serum HCO3 25 mmol/L. eupneic without distress. During dialysis, he observed develop increasingly worse mentation. found have (pH 7.01, 123 83 while NC) placed BiPAP improvement. The at the time 30 mmol/L by Henderson-Hasselbach equation. Acute suspected NIPPV subsequent sessions further episodes failure. DISCUSSION: Dialysate prescriptions contain supraphysiologic [HCO3] that predispose underlying hypercapnia via mechanisms. Abrupt bicarbonate influx from dialysate acutely increases blood which can cause effects central peripheral chemoreceptors [1]. Furthermore, nonvolatile acids react exogenous producing CO2 then returns patient venous line transiently contributes OSA or [2]. reduction circulating [H+] also reduces ionized calcium diaphragmatic weakness promote CONCLUSIONS: Hemodialysis precipitate known and/or OHS. Identifying risk phenomenon facilitate early intervention adjustment prescription reduce likelihood developing flux as discussed previously. suspect is underreported investigation interest. REFERENCE #1: Symreng T, Flanigan MJ, Lim VS: Ventilatory metabolic during high efficiency hemodialysis. Kidney Int 1992;41:1064-1069. #2: Sombolos KI, Bamichas GI, Christidou FN, Gionanlis LD, Karagianni AC, Anagnostopoulos TC, Natse TA. increment post-dialyzer blood: role dialysate. Artif Organs. 2005 Nov;29(11):892-8. doi: 10.1111/j.1525-1594.2005.00126.x. PMID: 16266303. DISCLOSURES: No relevant relationships Zachary Chandler, source=Web Response Nimeh Najjar, Peter Staiano, Spencer Streit,