Intradialytic Hypotension
Fadel A. AlRowaie , MD ,FACP ,FNKF
Assistant Professor of Medicine (KSAU-HS)
Consultant Nephrologist
Head of Nephrology (KFMC)
Outline
• Introduction
– Definition
– Epidemiology
– Clinical consequences
• Pathogenesis
– Water movement and vascular refilling
– Cardiovascular response to UF
• Interventions to reduce intra-dialytic
hypotension
Clinical scenario
UF stopped
Qb reduced
IVF 250 cc 0.9NS
Schreiber MJ Jr. Am J Kidney Dis. 2001 Oct;38(4 Suppl 4):S37-47
Introduction
Hypotension that require nursing intervention or
medical treatment occurs in 10-30% of
hemodialysis treatment (HEMO study :18.3% vs.
16.8% )
McCausland FR, et al .Am J Nephrol. 2013;38(5):388-96
Intra-dialytic Hypotension
(IDH) is defined as a decrease in
systolic blood pressure by ≥20 mm Hg
or a decrease in MAP by 10 mm Hg
associated with symptoms & need for
nursing intervention
 K/DOQI Workgroup. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis
patients. Am J Kidney Dis. 2005 Apr;45(4 Suppl 3):S1-153
 Kooman J, Basci A et al. EBPG guideline on haemodynamic instability. Nephrol Dial Transplant. 2007
May;22 Suppl 2:ii22-44.
Clinical significance
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•
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Increased mortality
Access thrombosis
Under-dialysis and volume overload
Organs ischemia ( MI , CVA and ischemic
bowel)
• Increase nursing intervention
Always consider and exclude the following
serious conditions:
•
•
•
•
•
•
•
Arrhythmia
Pericardial tamponade
Valvular disorders
Myocardial infarction
Hemolysis & hemorrhage
Septicemia
Air embolism
Shoji T. et al . Kidney Int. 2004 Sep;66(3):1212-20
Vascular access thrombosis is more frequent with grafts than with fistulas.
Chang T I et al. JASN 2011;22:1526-1533
©2011 by American Society of Nephrology
Subjects with more frequent episodes of intradialytic hypotension are more likely to experience vascular
access thrombosis.
Chang T I et al. JASN 2011;22:1526-1533
©2011 by American Society of Nephrology
Pathogenesis of IDH
Water movement during hemodialysis
ECF
ICF
Dialyzer
Step 3
Water movement
Step 1
280
Loss of
urea/H2O
Osmolality
320 mosmol/kg
Osmolality
320 mosmol/kg failing
to 290 mosmol/kg as
diffusion occurs
Step 2
Stroke volume X
Heart rate
Cardiovascular responses to plasma volume depletion.
Reilly R F CJASN doi:10.2215/CJN.09930913
©2014 by American Society of Nephrology
Patients at risk of IDH
• 65 years or older age
• DM
• Patients with CVD:
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LVH and diastolic dysfunction with or without CHF
LV systolic dysfunction and CHF
Valvular heart disease
Pericardial disease (constrictive pericarditis or pericardial effusion)
Poor nutritional status and hypoalbuminemia
Hyperphosphatemia
Uremic neuropathy or autonomic dysfunction due to other causes
Severe anemia
Patients requiring high volume ultrafiltration; more than expected
interdialytic weight gain
• Patients with predialysis SBP of <100 mm Hg
Acute Management of IDH
•
•
•
•
Reduce the rate or stop the ultrafiltration
Place patient in Trendelenburg position
Reduce blood flow
IVF 250 ml of 0.9 % NS bolus (can be repeated) / albumin &
manitol are alternatives
• Exclude serious condition
Albumin Vs. Saline for treatment of IDH
Knoll GA . J Am Soc Nephrol. 2004 Feb;15(2):487-92
Interventions to reduce intra-dialytic hypotension
• Patient related intervention
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Accurate setting of the "dry weight“
Minimize inter- dialytic weight gain
Reduction of salt intake to 2g/ 90 mmol Na per day (6 g/d NaCl)
Avoidance of food during dialysis
Avoid antihypertensive medicines on dialysis day
• Dialysis related intervention
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High dialysate Na / Na profiling
Sequential ultrafiltration and isovolemic dialysis
Blood volume monitoring & biofeed back dialysis
Low dialysate temperature
Bicarbonate buffer
High dialysate Ca++
Hemofiltration and hemodiafiltration
Prolonged & frequent dialysis
• Pharmacological intervention
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–
Midodrine
Carnitine
Water movement during isolated ultrafiltration
ECF
ICF
Dialyzer
Step 3
Water movement
Osmolality
320 mosmol/kg
Osmolality
320 mosmol/kg with
raising plasma
oncotic pressure
Iso-osmotic loss
of solutes/H2O
Step 1
Step 2
Change in Na & weight post dialysis
Reddan DN et al .J Am Soc Nephrol. 2005 Jul;16(7):2162-9
Biofeedback dialysis for hypotension and hypervolemia: a
systematic review and meta-analysis
Nesrallah GE et al.Nephrol Dial Transplant. 2013 Jan;28(1):182-91
• Guideline 3.1.2a Individualized, automatic BV
control should be considered as a second-line
option in patients with refractory IDH
(Evidence level II).
• Guideline 3.1.2b Manual adjustment of
ultrafiltration according to a fixed protocol
based on changes in blood volume should
not be performed (Evidence level II).
Kooman J, Basci A et al. Nephrol Dial Transplant. 2007 May;22 Suppl 2:ii22-44.
Low dialysate temperature
There are two different ways of reducing
dialysate fluid temperature:
• Empiric fixed reductions of dialysate
temperature
• Isothermic dialysis, a technique in which body
temperature remains constant via the use of a
biofeedback temperature-controlled device
Jost CM et al.Kidney Int. 1993 Sep;44(3):606-12.
Selby NM et al .Nephrol Dial Transplant. 2006 Jul;21(7):1883-98
Bicarbonate dialysate vs. Acetate
The frequency of IDH during HD
using acetate dialysate
Non IDH
IDH
The frequency of IDH during HD
using bicarbonate dialysate
Non IDH
IDH
2%
44%
56%
98%
Thaha M. et al.Acta Med Indones. 2005 Jul-Sep;37(3):145-8
High calcium dialysate & Ca profiling
Kyriazis J et al. Kidney Int. 2002 Jan;61(1):276-87
The addition of High Dialysate Ca to
midodrine and/or cool dialysate further
improves blood pressure in patients with
IDH. However, this therapy did not reduce
symptoms or interventions required for
IDH.
In
addition,
hypercalcemia
complicated this therapy in 22% of the
patients.
Alappan R et al. Am J Kidney Dis. 2001 Feb;37(2):294-9.
Midodrine
•
Midodrine is an oral prodrug with selective α-1 adrenergic agonist activity.
•
The drug was released into clinical practice in 1996 as a new treatment for patients
with symptomatic orthostatic hypotension.
•
is rapidly absorbed in the GIT and converted to the active metabolite,
desglymidodrine, in the systemic circulation
•
The prodrug achieves peak levels in 60 minutes. The absolute bioavailability of
desglymidodrine is 93% for oral tablets, and it reaches peak levels in approximately
60 to 90 minutes.
•
Excretion of the drug is primarily renal , the half-life of desglymidodrine, is 3.5 hours
on HD & 9 hours on nondialysis days
•
The major adverse events were piloerection (13%) and pruritis (10%)
Perazella MA.Am J Kidney Dis. 2001 Oct;38(4 Suppl 4):S26-36
Prakash S. Nephrol Dial Transplant. 2004 Oct;19(10):2553-8
Comparison between various
interventions to prevent IDH
Dheenan S. Kidney Int. 2001 Mar;59(3):1175-81
Dheenan S. Kidney Int. 2001 Mar;59(3):1175-81
EBPG guideline on haemodynamic
instability
First-line
approach
Second-line
Third-line
approach
approach (only if
Dietary counselling
(sodium
o Try objective
methods to assess dry
restriction).weight. other treatment options have
Refraining
food
intake
during failed)
o from
Perform
cardiac
evaluation.
o
o
o
o
o
o
o
dialysis. o Gradual reduction of dialysate
o offrom
Consider
midodrine.
Clinical reassessment
dry 36.5°C
temperature
downward
o Consider
l-carnitine
supplementation.
weight.
(lowest 35°C)
or isothermic
treatment
o dialysis
Considerconvective
peritoneal dialysis.
Use of bicarbonate
(possible as
alternative:
buffer.
treatments).
Use of aodialysate
Considertemperature
individualizedofblood volume
36.5°C.
controlled feedback.
Check dosing
and timing
o Prolong
dialysisof
time and/or increase
dialysisagents
frequency.
antihypertensive
o Prescribe a dialysate calcium
concentration of 1.50 mmol/l.
Kooman J, Basci A et al. Nephrol Dial Transplant. 2007 May;22 Suppl 2:ii22-44.
Dialysate sodium
Guideline 3.2.1 :
Although sodium profiling with supraphysiological
dialysate sodium concentrations and high sodium
dialysate (≥144 mmol/l) are effective in reducing IDH,
they should not be used routinely because of an
enhanced risk of thirst, hypertension and increased
inter-dialytic weight gain (Evidence level II).
falrowaie@kfmc.med.sa
@fadelrowaie