Dialysis headache in sufferers present process peritoneal dialysis and hemodialysis

Dialysis headache in patients undergoing peritoneal dialysis and hemodialysis
May 5, 2021 0 Comments


Dialysis prevents growth and/or progress of uremia-related problems, equivalent to neuropathy and encephalopathy, however the remedy itself might result in acute or long-term neurological problems. Though headache is among the many most regularly encountered neurological signs throughout hemodialysis (HD), research reporting its options are restricted. Even scarcer are knowledge on headache related to peritoneal dialysis (PD).1

Based on the Worldwide Headache Society (IHS) standards, dialysis headache (DH) is characterised by occurring throughout at the least half of HD classes, resolving inside 72 h after dialysis or altogether after profitable transplantation and by at the least three assaults with these properties.2 All standards are associated to HD.

The pathophysiology of DH continues to be unresolved. One suggestion was that the massive water and electrolyte shifts throughout dialysis might induce headache. That is significantly necessary for HD, which is related to extra exceptional variations of hemodynamic parameters than PD. The complications described in HD sufferers might signify an integral a part of the so-called post-dialysis disequilibrium syndrome.3 One other doable related trigger would be the presence of hypertension throughout HD. A optimistic correlation between the severity of hypertension and the probability of headache to happen throughout HD was reported, although the absence of hypertension doesn’t essentially preclude the prevalence of DH.4 There may be nonetheless little or no knowledge accessible on complications associated to PD remedy.

On this examine, we aimed to evaluate the frequency and scientific options of DH in HD and PD sufferers.

Materials and strategies

This potential examine included 409 sufferers from 4 dialysis facilities in Serbia—91 on PD (43 females and 48 males, imply age 59.75 ± 11.53 years) and 318 on HD (119 females and 199 males, imply age 59.90 ± 12.73 years). All PD sufferers had been on steady ambulatory peritoneal dialysis with 4 every day exchanges of two L of glucose-based dialysate. All HD sufferers had been on customary bicarbonate HD, carried out thrice weekly for 4 h, utilizing polysulfone dialyzers. Time on dialysis ranged from 3 to 60 months in PD sufferers and from 3 to 240 months in HD sufferers. Majority of sufferers on each dialysis modalities had been handled with recombinant human erythropoietin. All sufferers gave their knowledgeable consent for participation within the analysis. The examine was performed in compliance with the Declaration of Helsinki.

All sufferers had been interviewed by a single skilled neurologist, utilizing a questionnaire primarily based on the Worldwide Headache Classification diagnostic standards. The questionnaire offered particulars on the time of headache onset, month-to-month incidence of signs, ache severity assessed by verbal-analogue scale (0 representing “no ache”, 10 representing “the strongest ache” as estimated by the affected person), high quality of the ache (pulsating/throbbing and non-pulsating), location (anterior and posterior features of the top), lateralization (unilateral, bilateral, and diffuse), period of the ache (in minutes) and related signs (photophobia, phonophobia, osmophobia, nausea, vomiting, vertigo, and weak spot of physique components). All sufferers with repeated complications underwent thorough neurological examination and in some circumstances additional diagnostic procedures had been indicated.

Blood samples had been drawn following 12-h in a single day fasting, that’s, after the evening change in PD sufferers and earlier than heparin administration in the beginning of HD session. Serum urea nitrogen was measured by full enzymatic methodology (urease–glutamate-dehydrogenase), reference vary was 3.5–7.5 mmol/L. Serum calcium focus was decided by photometric shade take a look at (Arseniko), reference vary was 2.20–2.65 mmol/L. Serum phosphates had been decided by photometric UV-test, reference vary being 0.80–1.45 mmol/L. Serum calcium and phosphates had been calculated as imply values from two measurements in two consecutive months, carried out previous to laboratory investigations and interview. Serum creatinine was decided by the Jaffe’s kinetic methodology with out deproteinization on multichannel analyzer. Serum sodium and potassium concentrations had been decided by flame photometry. Hemoglobin focus was decided by cyanmethemoglobin methodology on Coulter’s analyzer. Peritoneal dialysis adequacy was assessed primarily based on Kt/Vsp index, calculated from system: Kt = whole Kt = peritoneal Kt+renal Kt; peritoneal Kt = −h dialysate urea nitrogen content material/serum urea nitrogen; renal Kt = −h urine urea nitrogen content material/serum urea nitrogen.

V (by Watson system): V = 2.447 − 0.09516 A + 0.1074 H + 0.3362 W (in males),

V = −2.097+0.1069 H+0.2466 W (in females), the place A = age (years), H = peak (cm), and W = weight (kg). Hemodialysis adequacy was assessed primarily based on Kt/Vsp index, calculated from Daugirdas second-generation system: the place C1 is predialysis serum urea, C2 is postdialysis serum urea (mmol/L), T is period of dialysis session in hours (h), UF is interdialysis weight achieve (L), and W is the sufferers’ postdialysis weight (kg).

Reference values for sufficient dialysis in response to KDOQI tips are weekly Kt/V >2 for PD sufferers and Kt/Vsp ≥1.2 for HD sufferers.1 Arterial blood stress (BP) was calculated as imply worth from 12 measurements taken earlier than and after mid-week HD session or first every day change in PD sufferers. Outcomes had been statistically analyzed with Chi-square take a look at, t-test for parametric and Mann–Whitney take a look at for non-parametric knowledge. p < 0.05 was thought-about important.


Primary demographic and scientific knowledge and underlying renal illness are proven in Desk 1. No statistically important variations had been discovered concerning age and intercourse between PD and HD sufferers. Nonetheless, underlying renal illness in HD sufferers was largely parenchymal, whereas in PD sufferers it largely had vascular etiology (Desk 1). Majority of sufferers had sufficient dialysis (Desk 1).

Desk 1. Demographic and scientific traits.

PD sufferers had considerably decrease serum sodium, potassium, calcium, phosphate, calcium–phosphate product, urea and creatinine, and considerably increased serum hemoglobin than HD sufferers (Desk 2). Systolic BP didn’t differ considerably amongst PD and HD sufferers, whereas diastolic BP was considerably decrease in PD sufferers (Desk 1).

Desk 2. Biochemical traits of the examine teams.

Solely three sufferers (2 males and 1 girl) had complications earlier than beginning CAPD. Two topics had episodic tension-type headache and one had occipital neuralgia. Not one of the sufferers noticed modifications in headache traits following the start of PD remedy (Desk 3). Preexisting complications had been current in 53 (16.7%) HD sufferers (31 ladies and 22 males), largely identified as tension-type (43.4%) and migraine (26.4%). Most HD sufferers noticed no modifications within the traits of main headache in connection to the start of persistent HD remedy (Desk 3). Not one of the sufferers with main complications skilled assaults of their typical headache throughout HD. Statistically important distinction was discovered between HD and PD sufferers concerning sorts of main headache (Desk 3).

Desk 3. Kinds of predialysis complications.

Dialysis headache was extra frequent in males, it usually started throughout the third hour of HD, and lasted lower than 4 hours. It was largely bilateral, non-pulsating and with out related signs, resembling tension-type headache and with out migrainous options (Desk 4).

Desk 4. Dialysis headache options in hemodialysis (HD) sufferers.


HD and PD are properly established modalities for treating finish stage renal illness sufferers in Serbia, with some 7,000,000 inhabitance and almost 5000 sufferers on HD and 300 sufferers on PD.

Dialysis headache was current in 6.6% of HD sufferers on this examine. Not one of the PD sufferers had DH. Earlier research reported 70% incidence of DH on HD,4 whereas newer researches registered DH in 50% of HD sufferers.3,5 Substantial lower in DH incidence could also be defined by advances in HD high quality. DH was extra frequent on acetate HD resulting from damaging base extra following acetate dialysis and reduce in carbon dioxide partial stress.4,6 Moreover, earlier research on this topic3,5 didn’t apply diagnostic standards from the revised ICHD from 2004, which had been utilized in our analysis classifying DH as a secondary headache dysfunction attributed to the dysfunction of homeostasis.2 It’s subsequently doable that these research included complications which had been current earlier than the start of persistent dialysis remedy, equivalent to migraine or hypertensive headache, as DH.7 HD and PD classic had no important affect on prevalence of DH in our examine. The identical discovering concerning HD sufferers was reported by different authors.8

Dialysis headache traits in our examine (male preponderance, look throughout the third hour of HD session, lower than 4 hours period, bilateral localization and non-pulsating high quality) had been considerably totally different from these reported by Goksan et al., the place DH on HD was extra usually current in feminine sufferers, had average depth, throbbing high quality and bilateral localization.3

Statistically important distinction was discovered between PD and HD sufferers in distribution of underlying renal illness. Sufferers handled with HD largely had parenchymal illnesses, whereas sufferers present process PD largely had vascular illnesses. This may be partially defined by the truth that vascular illness sufferers are referred to PD resulting from issues creating and sustaining sufficient vascular entry.

HD sufferers on this examine had considerably increased calcium, phosphate and calcium–phosphate product than PD sufferers. Excessive calcium–phosphate product is a vital danger issue for growth of extraskeletal calcifications, particularly diffuse, longitudinal calcifications of tunica media (Monckeber’s medial sclerosis).9 Such calcifications might lower elasticity of cerebral blood vessels, thus lowering their autoregulatory means and contributing to look of DH.1

Sufferers present process HD in our examine had considerably increased predialysis serum sodium, potassium, urea and creatinine than PD sufferers. A number of research of disequilibrium syndrome as a doable reason for DH reported considerably decrease serum sodium and urea in HD sufferers with DH.3,4,7,8 The disequilibrium syndrome might seem throughout HD, however it’s most typical on the finish or following a HD session. It’s attributed to acute cerebral edema in inadequately dialyzed sufferers, which seems resulting from quick elimination of gear from extracellular fluid.

Sufferers on common HD on this examine had considerably increased diastolic BP ranges than PD sufferers. Systolic BP was additionally increased in HD sufferers, however with out statistical significance. Of their examine of DH in HD sufferers, Goksan et al. reported considerably increased systolic and diastolic BP in sufferers with HD associated headache even earlier than beginning HD session.3 Alternatively, they didn’t observe distinction in BP after HD, concluding that sudden lower of arterial BP throughout HD might induce headache.3 Hypertension seems in early levels of renal failure and in majority of sufferers persists even after graduation of dialysis remedy.10 Being a extra steady course of, PD initially provided wonderful blood stress and quantity management, particularly for hemodynamically unstable sufferers.1 It was subsequently frequent apply to permit liberal salt and water consumption in PD sufferers. Nonetheless, quite a lot of latest research have proven that subclinical quantity growth inflicting hypertension is frequent in PD sufferers.11,12 The results grow to be extra apparent as soon as residual renal perform is misplaced. Extreme dietary salt consumption contributes to uncontrolled hypertension and quantity overload.1

Though the circumstances of caffeine-withdrawal headache have been described in HD sufferers, not one of the sufferers in our group of sufferers fulfilled standards for this dysfunction.13

Intermittent nature of HD calls for fluid elimination and electrolyte correction to be carried out over a short while interval and such fast elimination of fluid is commonly poorly tolerated.1 Extra fast lower of extracellular than intracellular urea focus and consequential osmotic fluid shift result in extra fast modifications of physique fluids quantity, together with cerebrospinal liquid, thus considerably contributing to elevated intracerebral stress, cerebral edema and headache in HD sufferers. This will additionally clarify why PD sufferers in our examine don’t undergo from DH, since elimination of particles and fluid throughout PD is extra gradual than throughout HD.

PD sufferers on this examine had considerably increased hemoglobin than HD sufferers. Headache could also be a symptom of anemia however correlation between full blood rely and headache has seldom been systematically studied. Moreover, Worldwide Complications Classification doesn’t embody anemia as doable reason for symptomatic complications, however quite consists of it within the appendix, along with different metabolic and systemic disturbances.2 Just a few epidemiological research reported contradictory outcomes on the correlation between anemia and complications. Due to this fact managed potential research are nonetheless wanted to find out incidence and properties of complications related to these states.2

In conclusion, biochemical alterations could also be implicated within the pathophysiology of DH. Particular options of DH would possibly contribute to raised understanding of this secondary headache dysfunction.

Desk 1. Demographic and scientific traits.

Attribute HD PD p
Age (years) 59.9 ± 12.73 59.75 ± 11.53 0.776
 Male 199 48 0.091
 Feminine 119 43  
 Passablea 139 29 0.838
 Non-satisfactoryb 131 29  
BP systolic (mmHg) 141.26 ± 23.189 137.42 ± 21.705 0.137
BP diastolic (mmHg) 88.5 ± 24.37 79.78 ± 12.315 0.029
Underlying renal illness      
 Vascular 86 49 0.000
 Parenchymal 141 20  
 Unknown 91 22  

Desk 2. Biochemical traits of the examine teams.

Variable CAPD HD p
Hgb (g/L) 112.1 ± 10.29 93.63 ± 15.53 0.000
Ca (mmol/L) 2.245 ± 0.224 2.335 ± 0.24 0.004
P (mmol/L) 1.598 ± 0.451 1.857 ± 0.565 0.000
Ca × P (mmol2/L2) 3.602 ± 1.057 4.324 ± 1.332 0.000
Okay (mmol/L) 4.392 ± 0.828 5.335 ± 0.868 0.000
Na (mmol/L) 138.78 ± 3.61 141.26 ± 3.81 0.000
Urea (mmol/L) 17.875 ± 6.235 29.028 ± 8.115 0.000
Creatinine (umol/L) 766.81 ± 206.91 886.73 ± 243.98 0.000

Desk 3. Kinds of predialysis complications.

Predialysis complications varieties HD PD p
Main, n (%) 41 (12.9) 2 (2.2) 0.002
Symptomatic, n (%) 12 (3.8) 1 (1.1) 0.313

Desk 4. Dialysis headache options in hemodialysis (HD) sufferers.

Headache options n (%)
Male intercourse 16 (76)
Solely throughout HD 15 (71)
Begining within the third hour of HD 11 (52)
Period lower than 4 h 16 (76)
Anterior localization 11 (52)
Bilateral presentation 17 (81)
Ache depth (VAS ≥8) 11 (52)
High quality of ache—non-pulsating 14 (67)
No related signs 14 (67)
Predialysis headache 0 (0)

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