Nephrology Hypertension

Hemodialysis: Acute Complications - Intradialytic hypotension

Does this patient have intradialytic hypotension?

Intradialytic hypotension is defined as a systolic blood pressure of less than 100 mmHg or a systolic blood pressure decrease of greater than 10 mmHg, or a mean arterial pressure decrease of greater than 30 mmHg with or without symptoms.

Symptoms result from decreased tissue perfusion, and vary in severity from mild to severe including fatigue, yawning, nausea with or without vomiting, dizziness, muscle cramps, abdominal pain or discomfort, restlessness, agitation, seizure, anxiety, acute vascular access thrombosis, syncope, transient ischemic attack, stroke, chest discomfort or chest pain, myocardial ischemia, cardiac arrhythmias, and sudden cardiac arrest.

What tests to perform?

  • This is a clinical diagnosis that relies on the review of the blood pressure values and the patient's symptoms

  • Laboratory tests and imaging studies that might help identify causes as well as severity of intradialytic hypotension:

    • EKG to exclude acute myocardial infarction or arrhythmias, especially if chest pain is present

    • Blood glucose to exclude hypoglycemia

    • Serum albumin to exclude hypoalbuminemia

    • Hemoglobin to exclude acute blood loss

    • Cardiac biomarkers (CK-MB, troponin T, troponin I) if chest pain or EKG abnormality is present

    • Transthoracic echocardiography if recurrent episode (to rule out pericardial effusion and to assess left ventricular ejection fraction)

    • 24-hour Holter-monitor to exclude cardiac arrhythmias

    • Serum cortisol to exclude adrenal insufficiency

    • Thyroid function tests to exclude subclinical hypothyroidism

    • Bioelectrical impedance analyses (BIA) to better estimate dry weight.

    • Chest x-ray if aortic dissection is suspected (depicting widening of mediastinum)

How should patients with intradialytic hypotension be managed?

Acute management

  • Place the patient in the Trendelenburg position

  • Reduce the ultrafiltration rate or stop ultrafiltration

  • Infuse boluses of 100 mL of 0.9% isotonic saline as necessary (first choice infusate). Infusion of salt poor human albumin offers no advantage over isotonic saline and is more costly (see meta-analysis)

  • Blood flow rate should not be routinely reduced as it has not effect on development of hypotension and this practice may result in inadequate dialysis.

  • Stop dialysis if hypotension is refractory

Prevention

Non-pharmacological prevention

  • Adjust estimated dry weight (increase by 0.5 kg if no edema or adjust weight using BIA)

  • Review and adjust use of anti-hypertensive drugs (dose and timing in relation to dialysis)

  • Counsel patient to limit interdialytic sodium intake and weight gain

  • Stop anti-hypertensive drug before dialysis

  • Avoid eating during dialysis

  • Adjustment of the dialysis prescription

    • Use cold (35.5-36oC) dialysate (benefit demonstrated in meta-analysis)

    • Limit ultrafiltration rate to < 0.35 mL/min/kg or total ultrafiltration to < 50 mL/kg

  • Use bicarbonate-based dialysate

    • Increase dialysate calcium to 3.0 mEq/L

    • Use sodium profile

    • Use ultrafiltration profile

    • Combined sodium and ultrafiltration profile

    • Perform isolated ultrafiltration, or ultrafiltration with sequential dialysis

    • Use biofeedback program (blood volume monitoring, BVM) (optional)

    • Consider hemodiafitration (optional, benefit not demonstrable in meta-analysis)

    • Consider more frequent hemodialysis (short daily or long nocturnal hemodialysis)

    • Consider switching to peritoneal dialysis if refractory or recurrent episodes

Pharmacological prevention

  • Prescribe midodrine 2.5-10 mg, 15-30 minute before dialysis (benefit demonstrated in meta-analysis). Starting dose is 2.5 mg in patient weighing < 70 kg, and 5 mg in patient weighing > 70 kg. Avoid midodrine in patient with active myocardial ischemia

  • Prescribe L-carnitine 20 mg/kg iv post-dialysis (optional, benefit not demonstrated in meta-analysis)

  • Consider sertraline 50-100 mg/day (optional)

  • Consider caffeine 250 mg during dialysis (optional)

What happens to patients with intradialytic hypotension?

What are the potential risks associated with recurrent intradialytic hypotension?

  • Inadequate dialysis

  • Delay in recovery of kidney function in acute kidney injury

  • Rapid decline in the residual kidney function

  • Chronic fluid retention

  • Vascular access thrombosis

  • Increased risk of cardiovascular events

  • Increased mortality risk

How to utilize team care?

  1. Nurse - Close monitoring in high-risk patients.

  2. Pharmacist - Review timing and dosing of anti-hypertensive medications, adherence to drug therapy, and monitor for drug-related side effects.

  3. Dietitian - counsel patients on low sodium diet (2 gm/day) and fluid restriction (1 liter/day)

  4. Specialist - Consider consulting cardiologist for evaluation of ischemic heart disease, heart failure, cardiac arrhythmia and pericardial effusion

Are there clinical practice guidelines to inform decision making?

Applications :not applicable

Limitations: paucity of systematic reviews and meta-analyses.

Other considerations

ICD-10-CM diagnosis code I95.3: Hypotension of hemodialysis

What is the evidence?

Hayes, W, Hothi, DK. "Intradialytic hypotension". Pediatr Nephrol. vol. 26. 2011. pp. 867-879.

Prakash, S, Garg, AX, Heidenheim, AP, House, AA. "Midodrine appears to be safe and effective for dialysis-induced hypotension: a systematic review". Nephrol Dial Transplant. vol. 19. 2004. pp. 2553-2558.

Selby, NM, McIntyre, CW. "A systematic review of the clinical effects of reducing dialysate fluid temperature". Nephrol Dial Transplant. vol. 21. 2006. pp. 1883-1898.

Mustafa, RA, Bdair, F, Akl, EA. "Effect of lowering the dialysate temperature in chronic hemodialysis: A systematic review and meta-analysis". Clin J Am Soc Nephrol. vol. 11. 2016 . pp. 442-57.

Dheenan, S, Venkatesan, J, Grubb, BP, Henrich, WL. "Effect of sertraline hydrochloride on dialysis hypotension". Am J Kidney Dis. vol. 31. 1998. pp. 624-630.

Donauer, J, Böhler, J. "Rationale for the use of blood volume and temperature control devices during hemodialysis". Kidney Blood Press Res. vol. 26. 2003. pp. 82-89.

Lynch, KE, Feldman, HI, Berlin, JA, Flory, J, Rowan, CG, Brunelli, SM. "Effects of L-carnitine on dialysis-related hypotension and muscle cramps: a meta-analysis". Am J Kidney Dis. vol. 52. 2008. pp. 962-971.

Rabindranath, KS, Strippoli, GF, Daly, C, Roderick, PJ, Wallace, S, MacLeod, AM. "Haemodiafiltration, haemofiltration and haemodialysis for end-stage kidney disease". Cochrane Database Syst Rev. vol. 18. 2006. pp. CD006258.

Fortin, PM, Bassett, K, Musini, VM. "Human albumin for intradialytic hypotension in haemodialysis patients". Cochrane Database Syst Rev. vol. 10. 2010. pp. CD006758.

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