Hemodialysis intolerance - unexpected clinical mask of critical myocardial ischemia

Caused by a variety of factors, poor hemodialysis (HD) tolerability is common in the population of hemodialysis patients and may significantly reduce their quality of life. Critical myocardial ischemia induced by intradialytic hemodynamic stress, and causative for HD intolerance is a rare, but life-threatening complication. Atypical clinical manifestations of myocardial ischemia in young patients could result in underestimation of acute coronary syndrome and sudden cardiac death risks. A 39-year-old female was admitted to the hospital complaining at severe fatigue and dizziness after every HD-session and during fitness activities. Back in 2002, she was diagnosed with systemic lupus erythematosus (SLE) and received glucocorticoids (GC) for a long time. Her lupus nephritis progressed to the end stage of kidney disease by 2007, and maintenance HD (MHD) was initiated. Kidney transplantation was performed in 2011, and she received standard immunospuression. Since 2017 she demonstrated progressive loss of the transplant function (chronic graft rejection), two years later transplantectomy was performed, and she re-started MHD via tunneled central venous catheter, because of repeated arteriovenous fistulas thrombosis occurred due to secondary antiphospholipid syndrome (APS) despite the anticoagulant therapy. At admission, ECG showed features of left ventricular (LV) hypertrophy and the isoelectric ST segment. Echocardiography (Echo-CG) confirmed preserved LV systolic function and absence of regional contractile impairment, though signs of marked LV hypertrophy and moderate calcification without severe valvular dysfunction were detected. Echo-CG and a Holter monitor (HM) test were performed during the HD session (intradialytic cardiac monitoring) to evaluate HD hemodynamics and identify the reasons for poor HD tolerability. Echo-CG was performed twice - 2 hours after the start of the HD session (‘hemodynamic stability’) and 30 min before the end of the session (‘hemodynamic stress’). HM-ECG data were analyzed for 12 hours, including HD time (fig. 1a, HM fragment before the session, isoelectric ST segment, HR 60). First intra-dialysis Echo-CG showed no signs of negative dynamics. The patient complained of increasing fatigue and dizziness 30 min before the end of HD, with arterial BP remaining within the normal range. Second Echo-CG detected regional hypokinesis progression in mid and apical segments of anterior and lateral LV walls (fig. 2, regional hypokinesis indicated by arrows). HM data showed a horizontal ST depression (>2.5 mm, HR 90) (fig. 1b). These findings of the intradialytic monitoring alongside with the patient’s complaints were interpreted as an atypical heart attack with transient myocardial ischemia, followed by a decision to perform a coronary angiography (CA). Critical stenosis (>85%) of the proximal segment of the left anterior descending artery was found (fig. 3, 3a oval zoom, the stenosis area is marked with an arrow). The coronary blood flow was completely restored after stenting the stenosis area (fig. 3b, 3b oval zoom, the stented segment is marked with an arrow). After the coronary intervention, the patient tolerates HD well and stays physically active in everyday life. Thus, the reported intradialytic hemodynamic stress acted as a stress test, inducing critical myocardial ischemia. The clinical manifestations of the painless myocardial ischemia were severe fatigue and dizziness at the end of the HD session. In terms of cardiorenal interactions, a periprocedural hemodynamic stress should be considered as a trigger of the coronary heart disease destabilization, commonly asymptomatic in everyday life. Early development and progression of coronary atherosclerosis in a young female patient may occur due to the multiple mutually aggravating causes: complicated SLE course, secondary APS, long-term treatment with GC and MHD vintage. The authors declare no conflict of interest.

maintenance hemodialysis, myocardial ischemia, echocardiography, Holter monitoring, coronary angiography