Hemodialysis Management in Hemorrhagic Stroke Patients

Dialysis Modality and Prescription

The American Heart Association recommends using cooled dialysate to improve hemodynamic stability and potentially protect against dialysis-induced brain injury, with a strength of evidence based on clinical guidelines 1, 2
The American College of Cardiology suggests starting blood flow slowly and increasing gradually to avoid rapid osmotic shifts that can worsen cerebral edema, based on practical summaries of clinical guidelines 1
The National Kidney Foundation advises implementing gentle fluid removal to prevent excessive ultrafiltration that may reduce systemic arterial blood pressure and exacerbate cerebral ischemia, with a level of evidence A 1
The European Society of Cardiology recommends avoiding rapid urea reduction, as osmotic shifts from acute urea clearance can increase intracranial pressure and brain water content, based on clinical guidelines 1

The American Heart Association states that hemodilution strategies are absolutely contraindicated in hemorrhagic stroke patients, as intentional hemodilution does not reduce mortality or improve functional outcomes and may worsen bleeding risk, with a Class III, Level of Evidence A 3, 4, 5

The American College of Cardiology recommends minimizing or withholding antiplatelet agents in hemorrhagic stroke, as they are only recommended for ischemic stroke and should be carefully considered only with strong indication in hemorrhagic cases, based on clinical guidelines 6
The European Society of Cardiology notes that there is no clear evidence supporting warfarin or NOACs in dialysis patients with hemorrhagic stroke, and controlled studies are lacking, with a level of evidence C 7

The American Heart Association recommends maintaining euvolemia with isotonic solutions, such as 0.9% normal saline, rather than hypotonic solutions, as hypotonic fluids can exacerbate cerebral edema, with a strength of evidence based on clinical guidelines 8
The National Kidney Foundation advises that volume expansion strategies without hemodilution are not recommended, with a Class III, Level of Evidence A 3, 4

The American College of Cardiology suggests targeting blood pressure <130/80 mmHg in patients with previous stroke and chronic kidney disease, though intensive BP control may be deleterious specifically in dialysis patients, based on clinical guidelines 6, 2
The European Society of Cardiology recommends monitoring for post-dialytic drops in systolic blood pressure up to 30 mmHg, which are associated with better survival, but greater decreases increase mortality, with a level of evidence B 2