Angina pectoris from metabolic alkalosis induced by dialysate bicarbonates in a hemodialyzed patient

Abstract A hemodialyzed women developed angina pectoris one hour after the end of the hemodialysis session, without the presence of a hypotensive episode, which resolved with the use of isosorbide dinitrate sublingually. She had diabetes mellitus, arterial hypertension, heart failure and known coronary artery disease (three-vessel disease), for which she was receiving treatment. The electrocardiogram showed a right bundle branch block (pacing rhythm). The episodes of angina pectoris recurred in subsequent sessions, always after the session and never the day after it. Blood gases (venous sample) were performed during the episode of angina pectoris and elevated bicarbonates were found (alkalemia pattern). The patient reported that she had not consumed animal proteins recently because she did not like them. The bicarbonates of dialysate were then reduced (from 33 to 30 mmol/L) and she was advised to increase her consumption of animal proteins, at which point the angina episodes ceased and the blood gas test (venous sample) after the end of the session did not show the presence of alkalemia (pH 7.334 and bicarbonates 26.5 mmol/L). The case is presented with related bibliographic investigation. Keywords Hemodialysis, metabolic alkalosis, angina pectoris, dialysate bicarbonates, diet proteins