Intradialytic hypotension

Dr Georges Halabi MER

Service de Dialyse Yverdon-Les-Bains Service de Nphrologie CHUV Lausanne

Definition
KDOQI Clinical Practice Guidelines for Cardiovascular Disease in Dialysis Patients
A decrease in systolic blood pressure by 20 mm Hg or a decrease in MAP by 10 mm Hg associated with symptoms that include: abdominal discomfort; yawning; sighing; nausea; vomiting; muscle cramps; restlessness; dizziness or fainting; and anxiety

EBPG guideline on haemodynamic instability

No evidence based recommendation regarding the definition of IDH can be given, the EBPG working group stresses that both a reduction in BP, as well as clinical symptoms with need for nursing intervention should be present in order to accept the presence of IDH. Conforming to the K/DOQI guidelines, a proposed definition is a decrease in systolic BP 20mmHg or a decrease in mean arterial pressure (MAP) by 10mmHg associated with clinical events and need for nursing

Prevalence
The reported incidence in cohort studies varies between 6% and 27%

958 patients Follow-up 10 months

F-IDH : > 10 events/10 months O-IDH: 1-2 events /10 months No-IDH: 8.0% 10.5% 8.9%

Nephrol Dial Transpl (2003) 18: 2601-2605

IDH in the HEMO study

Factor Intradialytic Hypotension Episode Cramps % 17.8% 6.6%

J Daugirdas Hemodialysis University september 2012

Intradialytic hypotension
The mechanism responsible for IDH is an inappropriate response of cardiovascular and neurohormonal systems to the acute plasma volume removal during dialysis

Hypovolemia
Plasma refilling

IDH

Cardiovascular reserve

Neurohormonal response

Plasma Refilling
Interstitial Space
Na
P H2O

Na K

UF
P

PR

Na Vascular Space

Vascular Space

Na

PR

oncotique pressure hydrostatic pressure John Wigneswaran

Mechanisms which can affect plasma Reffilling during Dialysis

Extravascular

Increase in hydrostatic capillary pressure

Compromised cardiac function Peripheral pooling of blood volume

Plasma Refill Rate

Interstitial Space Intravascular Vascular

Oncotic pressure changes

Hypoalbuminemia

Depletion of interstitial volume

Low dialysate sodium concentration High transcellular urea gradient Dry body weight error high UFR

Space

PR

Vascular Space

UFR

DeJager-Krogh phenomenon
Splanchnic and cutaneous circulations are extremely important blood reservoirs, the volume of which can contract during hypovolemia.

Impairment of peripheral vasoconstriction during volume removal

Acetate Release of cytokines (IL1-TNF-IL6) Autonomic neuropathy Thermal stress

Splanchnic Pooling

Cardiovascular reserve to hypovolemia

Venous tone Peripheral resistance Plasma volume Cardiac outpout Stroke volume

RAAS
Blood pressure Chemoreceptors activity Heart rate

Baroreceptors activity
Sympathic tone

Cardiac contractibility

Bezold-Jarisch Reflex

Intradialytic hypotension
Hypovolemia
Plasma refilling

IDH

Cardiovascular reserve

Neurohormonal response

Adenosine Vasopressine NO / Endotheline 1

Hypotension

Vasodilatation Decrease heart rate Decrease heart contractibility

Hypoperfusion

Adenosine release

Ischemia

adenosine-mediated cardiovascular effects result in deepening hypotension

Incidence

Rate

Prospective, observational pilot study of 20 chronic hemodialysis patients assessing the baseline AVP level and trend of AVP with ultrafiltration in patients with a diagnosis of IDH compared with patients without IDH. Ten symptomatic IDH patients and 10 controls were enrolled and matched for age, gender, and dialysis vintage. AVP levels were obtained hourly throughout the dialysis session and during hypotensive episodes.

BP

NO2 and NO3

Intradialytic hypotension
IDH is likely to be multifactorial and include a combination of patient and dialysis factors
Patient related
Non compliant patients
High interdialytic fluid intake Eating just before or during session Antihypertension drugs

Procedure related
Dialysate composition
Sodium Calcium Magnesium Buffer

Treatment Comorbidities
Atherosclerosis Cardiovascular diseases
LVH, arrhytmia, congestive heart failure Coronary heart disease, valvular heart diseases Pericarditis

Dialysate temperature

Iatrogenic
Incorrectly estimated dry weight High ultrafiltration rate Non-biocompatible materials Air embolism hemolysis

Diabetes Autonomic neuropathy Peripheral neuropathy Amyloidosis, Vasculatis Impaired venous compliance. Venous pooling Aberrant vasodilatation

Aim Assessment of relationship between intradialytic hypotension and mortality Patients 1,244 patients who underwent HD from 1999 to 2001 Results A greater fall in SBP is associated with increased mortality in all ranges of predialysis SBP

Consequences of IDH
Organ hypoperfusion

Cerebral Cardiac

Mesenteric

Semi-automated software

RWMA is defined as reduction in SF of >20% between baseline and peak images More than 2 RWMAs over 10 regions are significant

Myocardial stunning

Reduction myocardial blood flow

Change of regional SF Over time

Global reduction systolic cardiac function

Hemodynamic instability

Mortality

Mortality and first cardiovascular event

Dry weight
The lowest [post-dialysis] weight a patient can tolerate without intradialytic symptoms and/or hypotension and in the absence of overt fluid overload Henderson KI 17: 571-576; 1980 The post-dialysis weight at which the patient is and remains normotensive until the next dialysis in spite of interdialytic fluid retention and without antihypertensive medication Charra 1996 lowest tolerated postdialysis weight achieved via gradual change in postdialysis weight at which there are minimal signs or symptoms of hypovolemia or hypervolemia Rajiv Agarwal and Matthew R. Weir CJASN 2010

Assessment of volume status / dry weight

Clinical Judgement
Intradialytic hypotension is not synonymous of hypovolemia/underhydration Excess UF prescribed during HD can lead to hypotension without hypovolemia/underhydration. Some patients can be hypotensive while being hypervolemic (heart failure, diabetic patients). Postural hypotension is highly specific of hypovolemia but insentitive

Chest X-Ray
Not readily available at the bedside Not enough sensitive to detect OH Does not detect ECW-underhydration

US inferior vena cava

Needs experienced hands to achieve reproducibility Timing problem (refill post HD); 2h later may be the best timing

Blood Volume control

Continuous changes in Ht in response to UF. Ht rises mirrors BV reduction. Very sensitive to changes When the UF rate exceeds the plasma refilling rate and persists for long enough, a critical threshold is reached in the reduction of blood volume (BV). IDH may occure when a normal cardiovascular responses cannot compensate for large volume losses Detecting falls in relative plasma volume that preceded hypotension, allows preventative interventions ??.

M easurement of relative blood volume changes during haemodialysis: merits and limitations
Judith J. D asselaar, Roel M . H uisman, Paul E. de Jong and Casper F. M . Franssen
Nephrol Dial Transplant (2005) 20: 20432049

Characteristics of hypotension-prone haemodialysis patients: is there a critical relative blood volume?

Claudia Barth1, Walter Boer 2, D aniela Garzoni 3, Thomas K uenzi 4, Wolfgang Ries5, Ralf Schaefer 6, D aniel Schneditz7, Theoharis Tsobanelis8, Frank van der Sande9, Ralf Wojke10, Holger Schilling10 and Jutta Passlick-D eetjen 10
Nephrol Dial Transplant (2003) 18: 13531360

Table 6. Cumulative intra-individual variability of RBV crit SD O " 1% O " 2% O " 3% O " 4% O " 5% O " 6% All patients M ean" SD : 3.6" 2.1%. No. of patients 4 12 24 35 46 47 60 Sum (%) 6.7 20.0 40.0 58.3 76.6 78.3 100.0

Sensitivity of Blood Volume Monitoring for Fluid Status Assessment in Hemodialysis Patients
Francisco Maduell Marta Arias Elisabet Mass Nstor Fontser Montserrat Carrera Manel Vera Aleix Cases Josep M. Campistol

Blood Purif 2013;35:202208

Table 3. Data overview to figure 1 (RBV curves at different FO levels)

FO group, l 0.5 to 0.5 Patients, n Treatments, n UFV, l UFR, ml/h UFR index, ml/h/kg SBP before HD, mm Hg DBP before HD, mm Hg RBV slope full treatment, %/h RBV slope first 30 min, %/h RBV slope last 30 min, %/h RBV% at 260 min, % Slope 4 h, %/h/l/h Volume index, %/h/ml/h/kg 7 23 2.70.5 54582 8.22.0 11325 6118 2.1 6.0 3.8 88.04.8 3.90.6 0.270.06 0.5 to 1.5 11 32 2.60.4 53279 7.81.8 12417 6112 1.6 6.0 2.5 90.43.9 3.00.4 0.220.07 1.5 to 2.5 15 35 2.60.4 53877 8.22.1 13133 5615 1.0 7.6 2.2 91.04.7 1.90.4 0.140.04 2.5 to 3.5 16 31 2.70.3 55569 9.32.5 14027 6617 1.2 4.8 2.2 92.54.9 2.20.3 0.140.04 3.5 to 4.5 7 17 2.90.3 56761 8.11.4 14020 6418 0.6 6.0 0.8 94.03.2 1.00.1 0.080.01 4.5 to 5.5 4 10 2.60.3 51157 6.91.1 15315 626 0.3 1.2 1.2 97.75.4 0.60.1 0.050.01

Only treatments with a UF rate between the 25th and 75th percentile (400675 ml/h) and treatment time >10th percentile (>245 min) were included.

Sensitivity of Blood Volume Monitoring for Fluid Status Assessment in Hemodialysis Patients
Francisco Maduell Marta Arias Elisabet Mass Nstor Fontser Montserrat Carrera Manel Vera Aleix Cases Josep M. Campistol

Blood Purif 2013;35:202208

Fig. 2. ROC curves for three different FO cutoff values (2, 3, and 4 liters), using the Slope4h marker as the continuous variable.

Fig. 3. AUC and 95% CI for ROC classifications of FO using the

Slope4h marker.

N = 370 HD patients assessed as dry weight by nephrologists Pre dialysis

Bioimpedance spectroscopy in HD

Post dialysis

63% of 370 HD patients had fluid overload 5% of 370 patients were below the normal range 32% in the normal range

Aim
Achieving normohydration in HD patients

Fluid status (patients with intradialytic adverse events)

Patients
12 /52 patients with > two adverse events (AE) in the 4 weeks prior to the initial body composition measurement

Follow-up
400 134 days Results The fluid status was increased by 1.3 L resulting in a 73% reduction in intradialytic adverse events (P < 0.001). Drop in adverse events from 25.710.0% to 6.9 7.8% of treatments Blood pressure was not significantly increased

Patients grouped into 3 categories of increasingly severe pulmonary congestion

mild:14 comets moderate: 14 to 30 comets severe: >30 comets)

Natiuretic peptides
BNP / NT-proBNP Elevated in CKD stage 5, Reference values not formally known Reflect both volume overload and cardiac dysfunction

41

53 patients on 6 regimens of UF including constant, linear reduction, stepwise reduction and intermittent high UF rate interrupted by UF pauses, while simultaneously measuring relative blood volume.

Linear modelled UF was associated with an apparent reduction in hypotensive episodes, but this was not statistically significant. Stepwise and intermittent high UF models were associated with a significant increase in the frequency of symptomatic hypotension.

Ultrafiltration
There are limited data to support linear modelling of UF as a method of avoiding intradialytic hypotension. Few studies examining modelled UF alone, as it is usually examined in conjunction with sodium modelling. Based on limited evidence, nonlinear UF modelling alone may not be tolerated by some patients, and is best avoided in those prone to intradialytic hypotension.

3.1 Optimizing ultrafiltration: ultrafiltration profiling and blood volume controlled ultrafiltration
Guideline 3.1.1 Pulsed ultrafiltration profiles should not be used for the prevention of IDH (Evidence level III). 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).

Sodium activity
Gibbs-Donnan phenomenon [Na+]plasma water > [Na+]plasma

Gibbs Donnan
Sodium activity
= Na x Cl Na x Cl

Gradient Na Dialysat / Na plasmatique = - 3mmol/l

Interindividual variation
Predialysis plasma sodium concentration is relatively constant in hemodialysis patients.

1. Increasing dialysate sodium concentration improves refill from both the intracellular and interstitial spaces to the intravascular compartment. 2. However, increasing the sodium concentration in dialysate reduces dialytic removal of sodium. 3. Achieving eunatremic dialysate involves recognizing that each dialysis patient has a unique set-point for serum sodium 4. In eunatremic dialysis salt and water transport takes place by convection or ultrafiltration

A u d i t o f t h e Ef f ec t o f D i al y sat e So d i u m Co n c en t r at i o n o n In t er -D i al y t i c Wei g h t Gai n s an d Bl o o d Pr essu r e Co n t r o l i n Ch r o n i c Haem o d i al y si s Pat i en t s

Andrew Davenport
Nephron Clin Pract 2006;104:c120c125

Mean interdialytic weight gain 4.1% v 2.8% (p<0.05). Symptomatic hypotension 13.5% v 2.7% (p<0.05).
Dialysate Na, mEq/l Patients Age, years Male, % Pre-dialysis, S BP Pre-dialysis, DBP Post-dialysis, S BP Post-dialysis, DBP Ultraltration, % Pre-dialysis, Na mEq/l Post-dialysis, Na mEq/l Prescribed anti-hypertensives, % Different anti-hypertensives, n 6 140 251 57 (4469) 61.7 143 (127163.5) 79 (6688.5) 130 (114148.5) 72 (6381) 3.0 (2.064.0) 140 (139142) 140 (138141.5) 72.1 1.368 1.1 <140 188 56 (4569) 64.7 140 (124153)* 77.8 (6787) 126 (110140)** 72 (6280) 2.6 (1.83.3)** 139.6 (137141.5) 140 (138142) 40.4** 0.588 0.89**

* p < 0.05 vs. Na 140, ** p < 0.01 vs. Na 140. DBP= Diastolic blood pressure, mm Hg; S BP = systolic blood pressure, mm Hg. % ultraltration is the average mid-week weight loss compared to pre-dialysis weight. Data expressed asmedian values(inter-quartile range, 2575% ), or mean 8 standard deviation. Number of different anti-hypertensives refers to different classes of medication prescribed.

Sodium Gradient: A Tool to Individualize Dialysate Sodium Prescription in Chronic Hemodialysis Patients?
E. Lars Pennea, b Olga Sergeyevab

Blood Purif 2011;31:8691

UF
6

IDH
5 4 OR 3 2 1 0

16 15 Ultrafiltration rate (ml/min) 14 13 12 11 10 9 8

<6

<6

>6 to 3 >3 to 0 >0 to 3 >3 to 6 Sodium gradient (mEq/l)

>6

>6 to 3 >3 to 0 >0 to 3 >3 to 6 Sodium gradient (mEq/l)

>6

Fig. 1. Relation between sodium gradient and ultrafiltration rate.

Error bars represent 95% CI. Ultrafiltration rate was adjusted for sex, age, race and body weight.

Fig. 2. Hazard ratios of frequent intradialytic morbid events, as defined by saline infusions in 6 32% of the treatments, divided by sodium gradient. Sodium gradient 03 mEq/l is the reference group. Columns in white represent crude OR; columns in grey represent OR after adjustments for sex, age, vintage, diabetes and ultrafiltration rate normalized for body weight. Error bars represent 95% CI.

27 patients Pre HD [Na+] x 0.95 = Dialysis fluid [Na+] (ion-selective electrode) 135 mmol/l VersusStandard [Na+] =138 mmol/

Less thirst and intradialytic hypotension in the individualized Na+ period compared with standard phase. Less weight gain, and UFR in individualized Na+ period compared with standard phase.

Sodium modelling
A high initial dialysate sodium would offset the usual rapid decline in plasma osmolality that occurs early in haemodialysis (due to rapid removal of solutes)
reducing osmotic gradients across cell membranes, improving vascular refill reducing the fall in plasma volume

Later lower dialysate concentration would prevent net gain of sodium.

 Small heterogeneous groups Brief follow up Wide variety of profiles majority high-to-low Inappropriate comparisons, majority of profiles have high time average dialysate sodium concentration

Profling UF and Na

59

Original Article
Applying Sodium Profile with or without Ultrafiltration Profile Failed to Show Beneficial Effects on the I ncidence of I ntradialytic Hypotension in Susceptible Hemodilaysis Patients

AJNT

Amine Mohamed Hamzi1*, Mohamed Asseraji2, Kawtar Hassani1, Ahmed Alayoud1, Bahadi Abdellali1, Yassir Zajjari1, Dina Brahim Montacer 1, Ismail Akhmouch2, Mohamed Benyahia 1, Zouhir Oualim 1

3.2 Dialysate composition

3.2.1 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). From the data available, no difference in efficacy was observed between sodium profiling and non-profiled high sodium dialysis.

Fig. 2. Hourly intradialytic percent changesin s ys tolic blood pres s ure (SBP), dias tolic blood pres s ure (DBP), mean arterial pres s ure (MAP) and ymbolsare: ( ) dialys ate calcium proling (dCaP); ( ) low (1.25 mmol/L) dialys ate calcium (LdCa); ( ) medium (1.5mmol/L) cardiacindex (CI). S dialys ate calcium (MdCa); (*) s ignicant difference between dCaP group and both LdCa and MdCa groups . Data points repres ent mean values S EM. (S tudy A, N 18).

Nine cardiac patients (NYHAIII IV) mild-to-severe left ventricular dysfunction FE < 40%.

on the basis of these data, H-Ca dialysate is indicated during UF-HD in CCpts.

3.2 Dialysate composition

3.2.4 Dialysate Calcium Guideline 3.2.3 The use of a dialysate calcium concentration of 1.50 mmol/l should be considered in patients with frequent episodes of IDH, unless contra- indications are present (Evidence level II).

3.2 Dialysate composition

Guideline 3.2.4a Guideline 3.2.4.a In patients with frequent episodes of IDH, low (0.25 mmol/l) magnesium dialysate should be avoided, especially in combination with low-calcium dialysate (Level II).

 Randomised single blind crossover design 24 patients, 288 dialysis sessions six dialysate sequences with different potassium profiles The dialysis sessions were divided into 3 tertiles, casually modulating potassium concentration in the dialysate between the value normally used K and the two cut-off points K+1 and K-1 mmol/l. Haemodynamics were evaluated in a non-invasive manner using a finger beat-to-beat monitor.

Energy accumulation during dialysis

1. direct delivery of thermal energy by the extracorporeal circuit that overcomes the external energy losses; 2. increase in thermogenic metabolic rate as a consequence of biological mechanisms induced by the bioincompatility of the circuit materials; and 3. decreased dissipation of heat caused by cutaneous vasoconstriction as compensation for ultrafiltration-related hypovolaemia.

Nephrol Dial Transplant (2003) 18 [Suppl 7]: vii41vii45

Fourteen HD patients with a history of IDH were studied. During three mid-week HD treatments, CT was set to decrease by 0.5C (cooling) to remain unchanged at the baseline level (isothermic). Thermoneutral HD (no energy is added to or removed from the patient) was used as a control. Central blood volume (CBV), BP, skin temperature, heart rate variability [low and high frequency] were recorded.

IDH

Rate IDH

MAP POST DIALYSIS

CHANGE IN MAP

SYMPTOMES OF COLD

ADEQUACY OF DIALYSIS

Multicenter, open-label, randomized controlled study, assigned 146 long-term dialysis patients to HD (n 70), online predilution hemofiltration (HF; n 36), or online predilution hemodiafiltration (HDF; n 40). The primary end point was the frequency of intradialytic symptomatic hypotension (ISH).

Decrease 50.9%

Decrease 18.4%%

Reduction of hypotensive side effects during online-haemodia ltration and low temperature haemodialysis
Johannes Donauer 1, Christoph Schweiger 1, Brigitta Rumberger 1, Bernd K rumme2 and Joachim Bo hler 2

Nephrol Dial Transplant (2003) 18: 16161622

Seventeen patients with history of frequent hypotensive episodes during dialysis sessions (A) The first 25 HD treatments in comparison with 25 o-HDF sessions were evaluated using identical dialysate temperature. (B) In the second part of the study, o-HDF (n = 25) was compared with Temp-HD(n=25). In the latter method, the temperature of the dialysate was adjusted to result in identical energy transfer rates to those in the corresponding o-HDF. The number of hypotensive episodes, blood temperature and blood volume regulation were assessed.

4%

4%

Haemodiafiltration Does Not Reduce the Frequency of Intradialytic Hypotensive Episodes when Compared to Cooled High-Flux Haemodialysis
Jennifer H. Pinneya Thomas Oatesa Andrew Davenport b
Nephron Clin Pract 2011;119:c138c144

34 patients were converted to online post-dilutional HDF dialysis 44 patients remained on high-flux HD. Blood pressure and intra-treatment complications were monitored prospectively for 12 months. Themedian temperature was 36 C (35 C36 C), higher than the dialysate in the HD cohort which was 35C (35C36C),
Percent fall in MAP during session

Percent fall in MAP during session

16

15.0

*
12.5

12

*
HD HDF 4 2 0 2 4 Months 6 8 10 12

10.0

7.5 HDF HD

Fig. 3. Average percentage fall in mean arterial blood pressure

post-treatment in the HDF cohort, starting 3 monthsprior to conversion to HDF, and then for 12 months following conversion to HDF, and for 12 months in the HD cohort. Values expressed as means 8 SEM. * p ! 0.05 vs. HD. MAP = Mean arterial blood pressure.

Fig. 4. Percent fall in mean arterial blood pressure post-treatment in the HDF and HD cohorts. Values expressed as medians and interquartile range. * p = 0.032 vs. HD.

The frequency of intradialytic hypotensive episodes was greater for the HDF cohort: 25.9 versus 16.5% in the HD cohort, p = 0.0116.

3.5 Convective techniques and isolated ultrafiltration

Guideline 3.5.1 Haemo(dia)filtration techniques should not be considered a first-line option for the prevention of IDH, but as a possible alternative to cool dialysis (Evidence level II). Guideline 3.5.2 Sequential isolated ultrafiltration followed by isovolemic dialysis should not be used as a regular strategy for the prevention of IDH (Evidence level II).

retrospective cohort study. Subjects were those converted from CHD to SDHD (n=12).

Less hypotension was observed during treatment on SDHD: the odds ratio (95% confidence interval) was 0.36 (0.160.81; P=0.008).

3.6 Dialysis duration and frequency

Guideline 3.6 A prolongation in dialysis time or an increase in dialysis frequency should be considered in patients with frequent episodes of IDH (Levels IIIII).
8.Dheenan S,Henrich WL.Preventing dialysis hypotension:a comparison ofusual protectivemaneuvers.Kidney Int2001;59:1175 1181

H aemodialysis with on-line monitoring equipment: tools or toys?

Francesco L ocatelli 1, Umberto Buoncristiani 2, Bernard Canaud3, Hans K o hler 4, Thierry Petitclerc5 and Pietro Zucchelli 6

Blood Volume control

Fig. 1. Experimental des ign. The 36 enrolled patients were randomly as s igned to one of the two armsof the s tudy, differing for the s equence of conventional (A) and blood volume tracking (B) dialysis techniques (ABAB or BABA, res pectively), with each period las ting 4 weeks . At the end of the follow-up period 32 out of 36 patients were included in the s tatis tical analys is because of 3 protocol violators and 1 death.

A 30% reduction in intradialytic hypotension (IDH) events was observed in treatment B as compared with A (23.5% vs. 33.5%, P <0.004). the more IDH episodes in treatment A, the better the response in treatment B. The best responders to treatment B showed pre-dialysis systolic blood pressure values higher than the poor responders (P < 0.04).

34 hypotension-prone patients, cross-over study 6 weeksstandard HD versus BVM assisted HD: 50% responders 50% non responders

Arterial pressure

Arterial pressure controlled by varying UF rate

A randomized trial of 55 long-term, hypotension-prone hemodialysis patients tested a fuzzy logic system Severe IDH was seen in 13.8% of dialysis treatments in the control group, but only in 8.3% of sessions with the fuzzy logic system (39% relative reduction; P < 0.01)

IDH
Relative treatment effect estimate (rate ratio).

Absolute treatment effect estimate (rate difference).

SBP.

DBP.

Stratified approach to prevent IDH

First-line approach
Dietary counselling (sodium restriction). Refraining from food intake during dialysis. Clinical reassessment of dry weight. Use of bicarbonate as dialysis buffer. Use of a dialysate temperature of 36.58C. Check dosing and timing of antihypertensive agents.

Stratified approach to prevent IDH

Second-line approach
Try objective methods to assess dry weight. Perform cardiac evaluation. Gradual reduction of dialysate temperature from 36.58C downward (lowest 358C) or isothermic treatment (possible alternative: convective treatments). Consider individualized blood volume controlled feedback. Prolong dialysis time and/or increase dialysis frequency. Precribe dialysate Calcium 1.50 mmol/l

Stratified approach to prevent IDH

Third-line approach
Consider midodrine. Consider Lcarnitine supplementation. Consider peritoneal dialysis.

Access dry weight

Consider BCM do not rely only on clinical evaluation

Avoid unmonitored aggressive UF

is useful in detecting both hypervolemia and undervolemia

Consider Biofedback
BTM, BVM control

Pharmacologic Options Available to Treat Symptomatic Intradialytic Hypotension

Midodrine
Midodrine is an oral prodrug with selective a-1 adrenergic agonist activity. It raise blood pressure through constriction of both the venous and arterial systems mediated by direct a-1 receptor stimulation The drug was released into clinical practice in 1996 as a new treatment for patients with symptomatic orthostatic hypotension

M idodrine appears to be safe and effective for dialysis-induced hypotension: a systematic review
Suma Prakash, A mit X. Garg, A. Paul H eidenheim and Andrew A. H ouse
Nephrol Dial Transplant (2004) 19: 25532558

Six of 10 studies report improvement in symptoms of IDH, and there were no reported serious adverse events ascribed to midodrine

Table 3.

Approach to Midodrine Therapy in ESRD Patients With IDH

c Initiate midodrine therapy 30 minutes before HD c Start with 2.5 mg if patient , 70 kg or with 5 mg if . 70 kg c Titrate dose to correct blood pressure and symptoms Maximum dose approximately 30 mg predialysis c If blood pressure is still low during the last half of dialysis or postdialysis despite maximizing predialysis dose, Administer second dose of midodrine at midway point of dialysis Start with 2.5 mg and titrate up to correct blood pressure Maximum dose approximately 10 mg c Avoid midodrine in patients with active myocardial ischemia

Randomized, double-blinded, placebo-controlled trial in 22 hypertensive patients, effect of a constant infusion ofa non-pressor dose of vasopressin on the arterial pressure response during a hemodialysis in which the target fluid loss was increased by 0.5 kg over the baseline prescription

 Double blinded clinical trial, comparing the possible effect of intranasal DDAVP with intranasal distilled water as a placebo in prevention of intradialytic hypotension (IDH) in 17 patients with known symptomatic IDH Each group has 204 HD session (17 * 12). Hypotensive episode occurred 18 times (8.82%) in vasopressin group compared with 125 times (61.27%) p < 0.001