Intradialytic

Hypotension
Objectives
◦ Define intradialytic Hypotension
◦ Understand risk factors and physiology
◦ Know treatment and prevention strategies

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 “
In 2015, more than 32,000
filipinos underwent
hemodialysis treatment and
expected to double in 5 years.
-NKTI

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Hello!
I am Jake Estaca
2nd Year Internal Medicine Resident
GCGMH – Oct 2021

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1.
Definition
Intradialytic Hypotension
Definition - IDH
◦ KDOQI: Symptoms of low blood pressure
and decrease in SBP >20mmhg or decrease
in MAP >10mmhg.
◦ Systolic blood pressure <90mmhg.

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Epidemiology
◦ Complicates 5 to 30% of all dialysis treatments.
◦ A study that included 44,801 dialysis treatments, in
1137 patients 75% of patients had at least one episode
of intradialytic hypotension.
(Sands JJ et al. Hemodial Int. 2014 Apr; 18(2):415-22)

◦ In some patients, >50% of treatments are complicated

by intradialytic hypotension.
(Santos SF et al. Adv Chronic Kidney Dis. 2012 May;19(3):158-65)

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12 Billion
Philhealth 2018
pesos

32,000 Filipino
NKTI 2015, expected to double in 5 years

30%
Of this patients will have IDH

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Risk Factors
◦ Older age 65> years old
◦ Longer dialysis Vintage
◦ Diabetes
◦ Lower pre-dialysis blood pressure
◦ Lower Albumin
◦ Female gender
◦ Higher body mass index

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2.
Risk Factors
Intradialytic Hypotension
Causes of
Hypotension in Heart Rate
Hemodialysis
Patients

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Causes of IDH
Heart Rate Volume Cardiac Pump
◦ Tachycardia ◦ Rapid UF ◦ Heart Failure
◦ Atrial ◦ Excessive UF ◦ Pericardial
fibrillation ◦ Incorrect Dry Weight Tamponade
◦ Bradycardia ◦ Antihypertensives ◦ Valvular Heart
◦ Hypokalemia disease
◦ Eating before or
◦ Heart blocks during dialysis
◦ Hemorrhage
◦ Infection

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Rapid Ultrafiltration
◦ Ultrafiltration is the removal of Fluid during
Dialysis procedure.
◦ High volume UF rate causes intradialytic
hypotension.
◦ Fluid is removed from the blood vessels faster
than it can be replaced by the tissues.

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Inaccurate Dry Weight
◦ Sometimes the prescribed dry weight of the
patient is incorrect.
◦ If patient has no edema and lungs are clear, and
fluid removal is complicated by hypotension,
Contact the Nephrologist to reassess the
prescribed dry weight.

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Autonomic Dysfunction
◦ Most dialysis patients have nerve damage or
neuropathy.
◦ The inability of the sympathetic response to maintain
systemic blood pressure, especially during dialysis.
◦ It occurs in >50% of hemodialysis patients
particularly diabetics.

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Cardiac Problems
◦ Systolic heart failure
◦ Arrythmias
◦ Pericardial tamponade
◦ Valvular disorders- (AV/MV)
◦ Myocardial Infarction
◦ Ischemic Heart Disease

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Ischemic Heart Disease
◦ Causes the heart to receive less blood supply due to
cardiac injury or artery disease.
◦ N=18 hemodialysis patients with frequent intradialytic
hypotension were compared with 11 hemodialysis
patients with hemodynamic stability (no hypotension).
They underwent cardiac stress test to compare how
well the heart functioned under stress.
(Poldermans D. et al. Kidney Int. 1999;56(5):1905)

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Ischemic Heart Disease
Results
◦ Cardiac function similar at rest between 2 groups, but
during stress the hemodialysis patients with frequent
hypotension demonstrated worse cardiac function.
◦ Recommendation is to investigate underlying cardiac
disease in patients with frequent intradialytic
hypotension.

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3.
Clinical Presentation
Intradialytic Hypotension
Clinical Presentation
◦ Often Asymptomatic ◦ Nausea and Vomiting
◦ Fatigue ◦ Chest pain
◦ Malaise ◦ Shortness of breath
◦ Lightheadedness ◦ Syncope
◦ Muscle Cramps

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4.
Complications
Intradialytic Hypotension
Volume Overload
◦ Hypotension limit’s capacity to remove fluid
during dialysis.
◦ This leads to failure in achieving dry weight, and
consequent volume overload.
◦ Patient are given saline for hypotension.
◦ We increase the fluid target next treatment and
cycle repeats.

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Tissue Hypoperfusion
◦ Myocardial infarction
◦ Stroke
◦ Syncope
◦ Ischemic Bowel

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Access Thrombosis
◦ Increased risk of fistula thrombosis.
(HEMO study 2011)
◦ Randomized controlled trial. N=1426 hemodialysis
patients.
◦ Risk of thrombosis was doubled among those who
had hypotension in more than 30% of dialysis
treatments.
(Chang et al. J Am Soc Nephrol. 2011;22(8):1526)

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Increases all cause Mortality
◦ Retrospective observational cohort.
◦ N=6393 in-center, thrice weekly hemodialysis
patients in the US.
◦ Intradialytic hypotension (SBP <90 mmhg)
occured in 30% of treatments and was associated
with higher mortality.
(Flythe et al. AJKD. 2013;61(6):966)

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5.
Acute Management
Intradialytic Hypotension
Think about the Causes
Volume:
03 UF target?
Sepsis?
Fever or Chils?
Blood loss?
Heart Rate: Hemolysis?
Fast or slow?
Irregular?
Murmur?
01 02
Cardiac Pump:
Chest pains?
Heart failure?

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Acute Management
◦ Decrease or stop the ultrafiltration, depending on
the severity of the hypotension.
◦ Fluid bolus (250-500 ml saline)
◦ Supplemental oxygen
◦ Trendelenburg position

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Trendelenburg Position
◦ Head is tilted down (feet and legs are above the
level of the heart).
◦ Diverts blood from the lower extremities into the
central circulation.
◦ Improve cardiac filling and central blood volume.

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Limited Benefit of Trendelenburg
◦ Good example of an intervention that is based on
tradition rather than scientific evidence.
◦ Most studies show it does not reveal beneficial or
sustained changes in systolic blood pressure or
cardiac output.

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Limited Benefit of Trendelenburg
◦ N=10 normotensive subjects with Tagged RBC
were used to quantify blood volume distribution.
◦ Use of Trendelenburg increased blood volume by
only 1.8% (98 ml) in the upper compartment. No
significant hemodynamic or clinical benefit was
observed.
(Bivins et al 1985)

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5.
Prevention
Intradialytic Hypotension
Prevention
◦ Reassess dry weight.
◦ Avoid eating during dialysis.
◦ Review Antihypertensive Medications.
◦ Encourage patient to limit fluids and salt.
◦ Slow ultrafiltration.
◦ Consider longer dialysis time.
Cool Dialysate
◦ Typical dialysate temperature 37c.
◦ Consider reducing to 35.5 or 36c.
◦ Recommended by:
- 2005 KDOQI
- 2007 European Best Practice Guidelines.
◦ Increases systemic vascular resistance and
cardiac contractility.

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Cool Dialysate
◦ Meta-analysis comprised of 26 trials with total of 484 patients.
◦ Eleven of this trials provided sufficient information to allow calculation
of the pooled effect.
◦ Results: compared with standard dialysis, cool temperature dialysate
reduce the risk of IDH by 68% (95% CI).
◦ Analysis of nine trials (2548 dialysis sessions) showed that
uncomfortable symptoms on dialysis (Including feeling cold, Shivering,
or cramps) were 2.95 times more common with cool-temperature
dialysis (95% CI).
(Mustafa et al. Clin J Am Soc Nephrol. 2016 Mar; 11(3):442-57 )

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Midodrine
◦ Alpha 1 adrenergic agonist (sympathomimetic
vasoconstrictor).
◦ Considered in chronically hypotensive dialysis
patients, particularly with autonomic dysfunction.
◦ Given 30 minutes prior to HD or Halfway through
HD treatment.
◦ Improves chronic hypotension in HD patients by
modulating autonomic function and its direct effect on
peripheral vessels.

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Midodrine
◦ Meta-analysis of 10 Canadian studies.
◦ Results: Midodrine associated effects, increases
post –dialysis systolic and diastolic blood
pressure by 12.4 and 7.3 mmhg, respectively.

(Prakash et. Al. Nephro Dial Transplant 2004; 19(10):2553)

5.
Summary
Intradialytic Hypotension
◦ Hypotension is the most common complication seen
during Dialysis (30%).
◦ Compromises organ perfusion and increases risk of
access thrombosis and all cause mortality rate.
◦ Causes: Rate, Volume or Pump defect
◦ Minimize Risk: Adjust dry weight, Check medications
(Antihypertensives)
◦ Treat promptly: Assess for cause; saline; slow
ultrafiltration rate.
◦ Chronic Hypotension: Consider Midodrine or Cooling
of dialysate.
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Thank You
kaayo
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