Intradialytic Hypotension Patients Research Articles

Association of frequent intradialytic hypotension with the clinical outcomes of patients on hemodialysis: a prospective cohort study

Intradialytic hypotension (IDH) is a common complication of hemodialysis (HD), but there is no consensus on its definition. In 2015, Flythe proposed a definition of IDH (Definition 1 in this study): nadir systolic blood pressure (SBP) <90 mmHg during hemodialysis for patients with pre-dialysis SBP <159 mmHg, and nadir SBP <100 mmHg during hemodialysis for patients with pre-dialysis SBP ≥160 mmHg. This prospective observational cohort study investigated the association of frequent IDH based on Definition 1 with clinical outcomes and compared Definition 1 with a commonly used definition (nadir SBP <90 mmHg during hemodialysis, Definition 2). The incidence of IDH was observed over a 3-month exposure assessment period. Patients with IDH events ≥30% were classified as ‘frequent IDH’; the others were ‘infrequent IDH’. All-cause mortality, cardiovascular mortality, and all-cause hospitalization events were followed up for 36 months. This study enrolled 163 HD patients. The incidence of IDH was 11.1% according to Definition 1 and 10.5% according to Definition 2. The Kaplan-Meier curves showed that frequent IDH patients had higher risks of all-cause mortality (p = 0.009, Definition 1; p = 0.002, Definition 2) and cardiovascular mortality (p = 0.021, Definition 1). Multivariable Cox regression analysis indicated that frequent IDH was independently associated with a higher risk of all-cause mortality (Model 1: HR = 2.553, 95%CI 1.334–4.886, p = 0.005; Model 2: HR = 2.406, 95%CI 1.253–4.621, p = 0.008). In conclusion, HD patients classified as frequent IDH are at a greater risk of all-cause mortality. This highlights the significance of acknowledging and proactively managing frequent IDH within the HD patients.

#6050 TEMPORAL CHANGES IN PLASMA ENDOTHELIN-1 AND BLOOD PRESSURE DURING MAINTENANCE HAEMODIALYSIS

Abstract Background and Aims Endothelin-1 (ET-1) is a potent endothelium-derived vasoconstrictor that plays an important role in the regulation of arterial blood pressure (BP). Elevated levels of plasma ET-1 have been reported in patients with end-stage renal disease (compared with controls), patients on dialysis (compared with non-dialyzed uremic patients), and patients on haemodialysis (compared with peritoneal dialysis). It has been suggested that ET-1 plays a role in BP response to HD; however, the temporal association of changes in ET-1 with changes in BP during the course of an HD session has not been well defined. Moreover, conflicting results have been reported as to the patterns of intradialytic ET-1 changes, with different studies reporting either a decrease, an increase, or no change in ET-1 during HD. The aim of this study was to investigate temporal changes in ET-1 in patients with different intradialytic BP profiles. Methods Data was obtained from a prospective cohort study of 50 maintenance, thrice-weekly HD patients admitted to Brigham and Women's Hospital in Boston, MA, USA. BP was measured before, after, and every 15 min during dialysis using a calibrated ambulatory BP cuff. Blood samples were drawn before dialysis, at 30, 60, and 120 min into HD, and at the end of treatment. Following the exclusion of cases with missing data, shorter dialysis sessions, or very low pre-dialysis BP (below 85/55 mmHg), 42 patients were included in the analysis (17 females, median age 62 years, over 90% diagnosed with hypertension). One HD session was studied in each patient (median ultrafiltration 2.05 L, median duration 232 min). The patients were divided into three subgroups with different patterns of intradialytic systolic blood pressure (SBP): 1) patients with intradialytic hypotension (IDH) defined as: a) drop of SBP to or below 90 mmHg; or b) drop in SBP by at least 30 mmHg associated with at least two hypotension-related symptoms; or c) drop in SBP associated with multiple symptoms requiring intervention; 2) normotensive patients (NT) defined as patients in whom SBP remained between 90 and 130 mmHg for most of the HD session; 3) hypertensive patients (HT) defined as patients in whom the median intradialytic SBP was above 140 mmHg. Results 9 hypertensive patients (HT), 24 IDH patients, and 9 normotensive patients (NT) were identified. In the IDH group, at the end of HD, the median drop in SBP from the pre-HD level was 28 mmHg [25th–75th percentile 10–45 mmHg]. In HT and NT patients, SBP did not change significantly during HD. IDH patients had lower baseline ET-1 (2.2 pg/mL) compared with HT patients (3.4 pg/mL, P = 0.006) but similar compared with NT patients (2.3 pg/mL). ET-1 decreased over the course of dialysis in HT patients (P = 0.02) and NT patients (P = 0.008), whereas no change was observed in IDH patients (P = 0.30). At the end of HD, IDH patients had a similar ET-1 level (2.4 pg/mL) compared with HT patients (2.6 pg/mL) but higher compared with NT patients (1.4 pg/mL, P = 0.004). A moderate negative correlation was found between the dialysis-associated changes in ET-1 and SBP (r = –0.43, P = 0.005) as well as between the baseline ET-1 and baseline SBP in IDH patients (r = –0.42, P = 0.04). Conclusions HD patients may present various patterns of ET-1 changes during HD, which seem to be associated with BP response to HD. In particular, the patterns of ET-1 response to HD may vary among patients categorized as ‘hypertensive’ (the vast majority of patients in our study), who previously were observed to have an intradialytic increase in ET-1. Our results provide a possible explanation as to why previous studies that did not consider intradialytic BP patterns have yielded conflicting results regarding the direction of ET-1 changes during HD.

Evaluation of autonomic nervous system activity in intradialytic hypotension using entropy and skin sympathetic nerve activity.

The function of the autonomic nervous system (ANS) is crucial in the development of intradialytic hypotension (IDH). This study introduced the entropy of heart rate variability (HRV) and skin sympathetic nerve activity (SKNA) to provide a complementary nonlinear and dynamic perspective for evaluating ANS function concerning IDH. 93 patients undergoing hemodialysis (HD) were enrolled, and the baseline data, electrocardiogram (ECG), and SKNA were collected. The patients were separated into the IDH and nonIDH groups based on the thresholds, which were characterized as reductions in systolic blood pressure (SBP) of at least 20 mm Hg or mean arterial pressure (MAP) of at least 10 mm Hg. We developed a logistic regression model for IDH after analyzing the changes in the time domain, frequency domain, the entropy of HRV, and SKNA indices during HD. After 4-h HD, the detected results for heart rate, the ratio of low frequency and high frequency (LF/HF), and average SKNA (aSKNA) all increased in both groups. Nine out of the ten HRV indices and aSKNA in the nonIDH group were higher than those in the IDH group at most moments. aSKNA was positively correlated with heart rate (p = 0.0001) and LF/HF (p = 0.0005) in the nonIDH group, while the correlation disappeared in the IDH group, which indicated a worse ANS response in IDH patients. The logistic regression model exhibited the results of initial SBP [odds ratio (OR) 1.076; p = 0.001], and the difference between the last and first segments (DLF) of heart rate [OR 1.101; p =0.012] and LF/HF [OR 0.209; p =0.034], as well as the extreme value of the difference between other segments and the first segments (EOF) of aSKNA [OR 2.908; p =0.017], which were independent indicators for IDH. The new nonlinear and dynamic assessment perspectives provided by the entropy of HRV and SKNA help to distinguish differences in ANS patterns between IDH patients and nonIDH patients and have the potential to be used in clinical monitoring for HD patients.

Circumferential Strain as a Marker of Vessel Reactivity in Patients with Intradialytic Hypotension.

Background and Objectives: Intradialytic hypotension (IDH) complicates 4 to 39.9% of hemodialysis (HD) sessions. Vessels' reactivity disturbances may be responsible for this complication. Two-dimensional speckle tracking is used to assess arterial circumferential strain (CS) as a marker of the effectiveness of the cardiovascular response to the reduction of circulating plasma. Materials and Methods: The common carotid artery (CCA) and common iliac artery (CIA) CSs were recorded using ultrasonography in 68 chronically dialyzed patients before and after one HD session. Results: In patients with IDH episodes (n = 26), the CCA-CS was significantly lower both before (6.28 ± 2.34 vs. 4.63 ± 1.74 p = 0.003) and after HD (5.00 (3.53-6.78) vs. 3.79 ± 1.47 p = 0.010) than it was in patients without this complication. No relationship was observed between CIA-CS and IDH. IDH patients had a significantly higher UF rate; however, they did not differ compared to complication-free patients either in anthropometric or laboratory parameters. Conclusions: Patients with IDH were characterized by lower pre- and post-HD circumferential strain of the common carotid artery. The lower CCA-CS showed that impaired vascular reactivity is one of the most important risk factors for this complication's occurrence.

Application Value of Limb Ischemic Preconditioning in Preventing Intradialytic Hypotension during Maintenance Hemodialysis

Introduction: The aim of this study was to investigate the efficacy and safety of limb ischemia preconditioning (LIPC) in the treatment of intradialytic hypotension (IDH) in patients with maintenance hemodialysis (MHD). Methods: This was a single-center, prospective, and randomized controlled case study. A total of 38 patients with MHD who met the inclusion criteria from September 2021 to August 2022 were selected from the Blood Purification Center of our hospital. They were randomly divided into the LIPC group (n = 19) and the control group (n = 19). For patients in the LIPC group, the femoral artery blood flow was blocked with an LIPC instrument for 5 min (pressurized to 200 mm Hg) before each dialysis, and they were reperfused for 5 min. The cycle was repeated five times, with a total of 50 min for 12 weeks. The control group was pressurized to 20 mm Hg with an LIPC instrument, and the rest was the same as the LIPC group. The blood pressure of 0 h, 1 h, 2 h, 3 h, 4 h, and body weight before and after hemodialysis were measured in the two groups during hemodialysis, the incidence of IDH and the changes of serum troponin I (TNI) and creatine kinase isoenzyme MB (CK-MB) levels before and after the intervention were observed, and the ultrafiltration volume and ultrafiltration rate were recorded. Results: At the 8th and 12th week after intervention, the MAP in the LIPC group was higher than that in the control group (103.28 ± 12.19 mm Hg vs. 93.18 ± 11.11 mm Hg, p = 0.04; 101.81 ± 11.36 mm Hg vs. 91.81 ± 11.92 mm Hg, p = 0.047). The incidence of IDH in the LIPC group was lower than that in the control group (36.5% vs. 43.1%, p = 0.01). The incidence of clinical treatment in IDH patients in the LIPC group was lower than that in the control group (6.3% vs. 12.4%, p = 0.00). The incidence of early termination of hemodialysis in the LIPC group was lower than that in the control group (1.6% vs. 3.8%, p = 0.01). The levels of TNI and CK-MB in the LIPC group after the intervention were lower than those in the control group (322.30 ± 13.72 ng/dL vs. 438.50 ± 24.72 ng/dL, p = 0.00; 159.78 ± 8.48 U/dL vs. 207.00 ± 8.70 U/dL, p = 0.00). The changes of MAP before and after the intervention were negatively correlated with the changes of TNI and CK-MB before and after the intervention (r = −0.473, p = 0.04; r = −0.469, p = 0.04). There were no differences in dry body mass and ultrafiltration rate between the two groups before and after the LIPC intervention (p > 0.05). Multiple linear regression analysis shows that TNI is the main influencing factor of ΔMAP. No LIPC-related adverse events were found during the study period. Conclusion: LIPC can effectively reduce the incidence of IDH in patients with MHD and may be associated with the alleviation of myocardial damage.

The Effect of Cooling Dialysate in Reducing Intradialytic Hypotension

Cooled dialysate incites peripheral vasoconstriction and thus counter Intradialytic Hypotension (IDH). Currently, up to 70 percent of IDH patients rely on cooled dialysate to ameliorate symptoms ranging from anxiety, restlessness, dizziness, muscle cramps, vomiting, nausea and abdominal discomfort. Presently, there is a plethora of research highlighting the effectiveness of cooled dialysate in ameliorating IDH. However, many of these studies have inherent weakness and thus may not be used to underline that cooled dialysate is indeed worthwhile. For example, the studies only relied on small samples. Further, the studies were conducted over fairly short periods of time. Consequently, to conclusively underpin the efficacy of cooled dialysate, it is necessary to undertake more in-depth research. The following document discusses the critical aspects of cooled dialysate.

Dynamic Echocardiographic Assessments Reveal Septal E/e' Ratio as Independent Predictor of Intradialytic Hypotension in Maintenance for Hemodialysis Patients with Preserved Ejection Fraction.

Background: Intradialytic hypotension (IDH) is a frequent and grave complication of hemodialysis (HD). However, the dynamic hemodynamic changes and cardiac performances during each dialytic session have been rarely explored in patients having IDH. Methods: Seventy-six HD patients (IDH = 40, controls = 36) were enrolled. Echocardiography examinations were performed in all patients at the pre-HD, during-HD and post-HD phases of a single HD session. A two-way analysis of variance was applied to compare differences of echocardiographic parameters between IDH and controls over time. The risk association was estimated by using a logistic regression analysis. Results: The IDH patients had a higher ejection fraction during HD followed by a greater reduction at the post-HD phase than the controls. Significant decreases in septal ratios of transmitral flow velocity to annular velocity (E/e’) over times were detected between IDH patients and controls after adjusting for gender, age and ultrafiltration (p = 0.016). A lower septal E/e’ ratio was independently associated with IDH (OR = 0.040; 95% CI = 0.003–0.606; p = 0.02). In contrast, significant systolic and diastolic dysfunctions over time were found in diabetic IDH compared to non-diabetic counterparts. Conclusion: The septal E/e’ ratio was a significant predictor for IDH.

Withdrawal

Some acute changes occur in the myocardium during a hemodialysis (HD) session and for understanding the causes and importance of these changes we need to conduct studies which may clarify the contradictory results published up to date. This study is aimed to evaluate the acute effects of HD on the myocardium using 3 dimensional speckle tracking echocardiography (3DSTE) in patients with and without hypotension during a dialysis session. We examined our HD patients who had normal ejection fraction (n=45) just before and after a HD session using 3DSTE. We recorded their demographic data, comorbidity status, renal replacement therapy characteristics and laboratory test results accordingly. Patients (n=12) with a history of intradialytic hypotension (IDH) occurring at least 30 % of their last 10 HD sessions formed the IDH group. The LV global longitudinal, circumferential area and radial peak systolic strain as well as RV Septum and Freewall longitudinal strain and fractional area change were calculated with 3DSTE analyses. After excluding 6 patients the data of the remaining 39 patients (18 males, 46.1 %, with mean age of 56.8 years) was analyzed. In the non-IDH group decreases observed in Septum LS, Freewall LS and FAC following HD sessions was found insignificant (p=0.57; p=0.12; p=0.16, respectively). In the IDH group RV volume indexes and EF decreased significantly (p= 0.001; p=0.01, respectively) and Septum LS, Freewall LS and FAC worsened significantly (p=0.04; p=0.05; p=0.03, respectively) following HD sessions. A significant stunning effect was observed in the RV. Except twist and torsion all LV strain parameters were changed in both groups. In the IDH group changes observed in the GLS, GCS, GRS and area strain were larger compared to the non-IDH group. There was significant worsening in LV strain measurements following HD sessions in both groups. HD treatment results in deterioration in all LV strain directions in both groups. RV strain parameters worsened statistically significant only in the IDH group. In patients with IDH the stunning effect of the session on both ventricles contributes to the long term effects of HD on the myocardium. Adjusting the ultrafiltration rate low in patients with IDH is also protective in RV strain deterioration and may break the vicious cycle preventing IDH patients to tolerate HD.

High ultrafiltration rate induced intradialytic hypotension is a predictor for cardiac remodeling: a 5-year cohort study

Background Intradialytic-hypotension (IDH) is a common complication of hemodialysis. High ultrafiltration rate (UFR) might lead to IDH. However, the relationships between UFR, IDH, and cardiac remodeling among hemodialysis patients in the long-term have not been deeply explored. Methods This retrospective cohort study collected clinical and echocardiographic data. Patients were enrolled from 1 January 2014 to 31 March 2014 and were followed-up for 5-year. Those who suffered from more than four hypotensive events during three months (10% of dialysis treatments) were defined as the IDH group. Subgroup analysis was done according to the UFR of 10 ml/h/kg. Associations between UFR, IDH, and alterations of cardiac structure/function were analyzed. Results Among 209 patients, 96 were identified with IDH (45.9%). The survival rate of IDH patients was lower than that of no-IDH patients (65.5% vs. 81.4%, p = .005). In IDH group, decreased ejection fraction (EF), larger left atrium diameter index (LADI), and left ventricular mass index (LVMI) (p < .05) were observed at the end of the follow-up. In multivariate logistic model, the interaction between UFR and IDH was notably associated with LVMI variation (OR = 1.37). After adjusting covariates, UFR was still an independent risk factor of LVMI variation (OR = 1.52) in IDH group. In subsequent analysis, we divided patients according to UFR 10 ml/h/kg. For IDH-prone patients, decreased EF, larger LADI, and LVMI (p < .05) were observed at the end of the study only in high-UFR group. Conclusions UFR and IDH have interactions on cardiac remodeling. High ultrafiltration rate induced IDH is a predictor for cardiac remodeling in long-term follow-up.

Association of Body Composition and Intradialytic Hypotension in Hemodialysis Patients

Background/Aim: The relationship between body mass index (BMI) and intradialytic hypotension (IDH) has been inconsistently reported, but no further research has investigated the correlation between body composition and IDH so far. This study aimed to determine whether the lean tissue index (LTI), fat tissue index (FTI), or both derived from body composition monitoring (BCM) is associated with IDH defined as a nadir intradialytic systolic blood pressure of <90 mm Hg and ≥3 episodes hypotension per 10 hemodialysis (HD) treatments in patients undergoing prevalent HD. Methods: The observational cohort study comprised 1,463 patients receiving thrice-weekly HD from 13 dialysis centers. LTI and FTI were assessed using a BCM machine, a multifrequency bioimpedance spectroscopy device. Unadjusted and multivariable adjusted logistic regression models were fit to estimate the association of body composition with the odds of developing IDH. Results: One hundred and seven patients (7.3%) were diagnosed as IDH. The difference in dialysis vintage, BMI, FTI, LTI, high-density lipoprotein cholesterol, and C-reactive protein between IDH and non-IDH groups was statistically significant (all p < 0.05). The prevalence of diabetes among IDH patients was slightly higher than among non-IDH patients. In logistic regression models, low LTI and high FTI, but not high BMI were associated with greater odds of IDH (“high” as above median and “low” as below median). When patients were further stratified into 4 distinct body composition groups based on both the LTI and FTI, only the low LTI/high FTI group was connected with a significantly higher odds of IDH (OR 2.686, 95% CI 1.072–6.734; reference: low LTI/low FTI group). Conclusions: The LTI and FTI can provide better correlation of IDH occurrence than the BMI alone in prevalent HD patients. The low LTI/high FTI appears to be most associated with IDH. An optimal body composition for preventing the occurrence of IDH needs to be determined.

Incidence And Characteristics Intradialytic Hypertension Among Chronic Hemodialysis Patients Caused By Chronic Kidney Failure At Rsmh Palembang Period November 2018

Intradialytic hypertension have 5 – 15 % incidence among chronic hemodialysis patients caused by chronic kidney failure. But, mostly medical practician focused only at intradialytic hypotension than intradialytic hypotension as the most frequent cardiovascular complications. Intradialytic hypertension itself is one of the cause of mortility and morbidity hemodialytic patients, that’s why patients should be aware of intradialytic hypertension. This study aims to know the frequencies of patients with intradialytic hypertension at RSMH Palembang period November 2018, and the characteristics of the patients based on patients sosiodemography, etiology of their chronic kidney disease, their hemodialysis period, and their activity during hemodialysis.Method : This study is descriptive analysis with total sampling, with primary data from patients blood pressure measurement, and interview with patients in hemodialysis installation at RSMH Palembang. In this study,305 samples were found, with 198 patients fulfilled inclusion criteria. Result : The result of this study shows that from 198 subjects, there are 116 (58,6%) of them who suffer intradialytic hypertension. Intradialityc hypertension patients mostly in the group age 46 – 65 years old (51%), male patients (61.2%) are more likely develop intradialytic hypertension than female patients (38.8%), patients with high educational backgroud also more likely to develop this complications. Their chronic kidney diseases cause are mostly hypertension (67,2%), and the higher activities patients during hemodialysis also more likely to develop intradialytic hypertension.Conclusion : Patients in hemodialysis installation at RSMH Palembang with intradialytic hypertension are more than the patients without the intradialytic hypertension (normotension and intradialytic hypotension patients are included), patients in old age group, male patients, and the higher patients activities during hemodialysis process the more highly patients develop intradialytic hypertension as complication.

Low Copeptin Levels in Patients With Intradialytic Hypotension.

Intradialytic hypotension (IDH) is related to high morbidity and mortality. There is evidence that arginine-vasopressin (AVP) responses could play a role. Copeptin is a reliable biomarker of AVP. In this study, copeptin, aldosterone, epinephrine, and norepinephrine levels in patients with IDH were evaluated throughout a hemodialysis (HD) session and compared with the control group. The study includes 15 patients who were normotensive during HD and 15 patients with IDH with a minimum HD vintage of 1 year. Blood samples were collected before the initiation of an HD session (T0 ), in the mid-session for control group, 30 min after mean arterial pressure drop for IDH patients (T1 ), and at the end of the session (T2 ). Groups had similar demographic features and health parameters, interdialytic weight gains, and ultrafiltration amounts. The IDH group had a mean arterial pressure decline of 39.9 (±6.4) mm Hg. Copeptin levels of the control group increased an average of 79.9 (±97.5) pmol/L at T1 and an additional 24.8 (±33.9) pmol/L at T2 . In the IDH group, copeptin level increases at T1 and T2 were 3.2 (±5.5) pmol/L and 34 (±44.6) pmol/L, respectively. Copeptin levels of the IDH group were significantly lower at T1 (P < 0.001) and at the T0 -T2 interval than control group (P = 0.05). In the control group, aldosterone levels distinctly decreased, and in the IDH group, aldosterone levels were elevated (P < 0.001). Small changes were detected in epinephrine and norepinephrine levels for both groups but did not reach significance (P = 0.6 and P = 0.3, respectively). Lower copeptin level alterations suggest inadequate AVP responses in patients with IDH.

FP641COMPARATIVE ANALYSIS OF DIAGNOSTIC METHODS FOR VOLUME STATUS ESTIMATION AND INTRADIALYTIC HYPOTENSION PREVENTION IN MAINTENANCE HAEMODIALYSIS PATIENTS

INTRODUCTION AND AIMS: To estimate volume status in maintenance haemodialysis (HD) patients by cardio-thoracic ratio (CTR) method, serum level of N-terminal brain natriuretic peptide (NTpro-BNP), colapsibility index (CI) of inferior vena cava method and by multifrequency bioimpendance analysis (BIA). We also wanted to make a correlation of these methods and to perform a dry weight correction according to the multifrequency BIA results of patient's volume status. According to that intervention we expected to decrease a number of patients with symptomatic intradialytic hypotension (IDH). METHODS: 128 patients on maintenance HD were tested for eligibility in Clinical Hospital Center Rijeka, Croatia, and 65 of them were enrolled in the study. According to the frequency of IDH patients were divided in two groups: 38 patients with frequent symptomatic IDH, and 27 patiens without frequent symptomatic IDH. Volume status was estimated in all patients by four methods: CTR, NTpro-BNP, multifrequency BIA and CI of inferior vena cava, at the beginning of the study and after six months. During a follow up period, dry weight of the patients was corrected by multifrequency BIA after one and three months, respectively. Results of volume status estimated by all four methods were correlated, and also was a frequency of symptomatic IDH and the beginning and at the end of the study. RESULTS: The mean age of the patiens was 64, 98 ± 11, 73 years, range from 38 to 85 years, and 35 (53, 85%) were men. The most common underlying renal disease was diabetic nephropathy in 19 (29%) patients. Comparative analysis of the volume status estimation by CTR, multifrequency BIA, IK of inferior vena cava, and NTproBNP indicated a significant correlation (at the beginning of the study and after six months). The number of symptomatic IDH in 38 (58%) patients decreased to the 11 (17%) patients at the end of follow up (p<0, 001). Risk factors for development of symptomatic IDH were older age (P=0, 041), and diabetes (p<0, 001). CONCLUSIONS: There is a great incidence of symptomatic IDH in the patients on the maintenance HD. The interdialytic weight gain, and the number of symptomatic IDH decreased by dry weight correction according to the multifrequency BIA. Comparative analysis of four methods for volume status estimation indicates a good correlation. Multifrequency BIA is objective, fast, non-invasive, without X-ray emission and highly reproducible method which could be used for volume status estimation and symptomatic IDH prevention in maintenance HD patients.

Nitric oxide production and blood pressure reduction during haemodialysis.

A decrease of systolic blood pressure in excess of 20 mmHg during haemodialysis treatment (IDD) is common for haemodialysis patients. Intradialytic hypotension (IDH) is symptomatic IDD by definition. Overproduction of nitric oxide (NO) is a possible cause of IDD. Dialysate nitrate and nitrite amount can be used as an indicator of intradialysis NO production. Our aim was to find the predictor of NO production in IDD patients. Partial dialysate samples were collected during the whole haemodialysis session and total dialysate nitrate and nitrite amount was measured to assess the association of intradialysis NO production with blood pressure change. There were 31 IDD patients and 71 patients who did not develop IDD (NIDD) included in the study. Among the IDD patients, 13 were IDH patients with a mean systolic blood pressure lower than that of the other 18 symptomless IDD patients (96.6 ± 3.4 mmHg vs 125.0 ± 3.8 mmHg, P<0.001). The median value of NO production was higher in the IDD than in the NIDD patients (447.7 μg vs 238.8 μg, P<0.001). The NO production correlated linearly with blood pressure reduction (R=0.487, P<0.001). The multivariate analysis showed that NO production was positively associated with predialysis systolic blood pressure. Nitric oxide production during haemodialysis was higher in IDD than in NIDD patients. IDH often occurred when systolic blood pressure was reduced to below 100 mmHg. The amount of NO produced during haemodialysis, which may be associated with predialysis systolic blood pressure, can be used to predict intradialysis blood pressure decrease.

Korean red ginseng improves blood pressure stability in patients with intradialytic hypotension.

Introduction. Intradialytic hypotension (IDH) is a common complication during hemodialysis which may increase mortality risks. Low dose of Korean red ginseng (KRG) has been reported to increase blood pressure. Whether KRG can improve hemodynamic stability during hemodialysis has not been examined. Methods. The 8-week study consisted of two phases: observation phase and active treatment phase. According to prehemodialysis blood pressure (BP), 38 patients with IDH were divided into group A (BP ≥ 140/90 mmHg, n = 18) and group B (BP < 140/90 mmHg, n = 20). Patients were instructed to chew 3.5 gm KRG slices at each hemodialysis session during the 4-week treatment phase. Blood pressure changes, number of sessions disturbed by symptomatic IDH, plasma levels of vasoconstrictors, blood biochemistry, and adverse effects were recorded. Results. KRG significantly reduced the degree of blood pressure drop during hemodialysis (P < 0.05) and the frequency of symptomatic IDH (P < 0.05). More activation of vasoconstrictors (endothelin-1 and angiotensin II) during hemodialysis was found. The postdialytic levels of endothelin-1 and angiotensin II increased significantly (P < 0.01). Conclusion. Chewing KRG renders IDH patients better resistance to acute BP reduction during hemodialysis via activation of vasoconstrictors. Our results suggest that KRG could be an adjuvant treatment for IDH.

Improved Management of Intradialytic Hypotension (IDH) using Vitamin E-bonded polysulfone Membrane Dialyzer

Intradialytic hypotension (IDH) is a common clinical trait in hemodialysis (HD) which is caused by poor biocompatibility of the dialyzer membrane. Aiming to improve IDH, vitamin E-bonded polysulfone dialyzer (VPS-H) was evaluated in a pilot study. Eight IDH patients on standard HD were switched from their conventional high-flux dialyzers to VPS-H, and intradialytic blood pressure (BP) was monitored regularly for 10 months. The results showed that hypotension of systolic BP (SBP), diastolic BP (DBP) and pulse pressure (PP) during the session were improved after changing the dialyzer. Notably, almost all the values recorded from 120 minutes into the session until the end of the treatment in the period between the second and tenth month after treatment were significantly different from the corresponding baseline values. Moreover, after 8 to 10 months, the SBP prior to a dialysis session was significantly reduced compared with baseline values. On the other hand, the pulse rate showed no difference throughout the study period. This study provides early evidence of the beneficial role that vitamin E-bonded dialyzers may have in preventing IDH. Larger controlled trials are needed to confirm this original finding.

Serum Vasopressin Response in Patients With Intradialytic Hypotension

Arginine vasopressin (AVP), an endogenous hormone with vasopressor properties, may be inadequately secreted during episodes of intradialytic hypotension (IDH). To evaluate this, we performed a 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. We observed that IDH patients experienced greater decreases in both systolic and diastolic blood pressure during the dialysis session despite equivalent ultrafiltration in both groups. AVP concentration did not increase in the IDH patients (5.0 +/- 1.8) compared with controls (6.4 +/- 6.0) (P = 0.5) despite hypotensive events. This study suggests that symptomatic IDH patients are unable to mount an appropriate increase in AVP secretion in the setting of hypotension. These findings support the possibility of AVP as a mechanism driven therapy for patients with symptomatic IDH.