step by step discussion in pit falls in treating a hypertensive patient undergoing dialysis

1. Virtual case presentation
Patient under dialysis with
uncontrolled hypertension
Haytham Soliman, MD
Fayoum university

2. History
• A 60 years old male
• Diabetic on insulin
• Obese with BMI of 40
• Hypertensive with uncontrolled hypertension
• ESRD due to advanced diabetic nephropathy

3. Primary care physician
• He requested an ECG denoting only LVH
• This was confirmed by echocardiography showing LVH, grade 2 DD
and no decrease in systolic LV functions
• He decided to monitor his blood pressure via office readings once a
week 2 hours post dialysis
- Creat : 5 mg/dl
- Hb: 10 gm
- LDL: 120
- HA1c: 7.5

4. Treatment
• Ramipril 5 mg once
• Atenolol 50 mg once
• ASA 81 mg once
• Atorvastatin 10 mg once
• Patient remain uncontrolled with BP: 170/96
• His doctor added to him torsemide 40 mg
• And still the patient is uncontrolled

5. Nephrologist
• He decided that this patient needs RRT in the form of hemodialysis
• He had a MDM with the primary physician
• They decided to give the patient 2 sessions of dialysis every week
• He did not set a special protocol for this patient in dialysis sessions

6. Patient
• He had a false sensation of safety due to dialysis
• He consumed 6gm of salt per day
• He had no fluid restriction
• He achieved and inter dialysis weight gain of 5 Kg

7. The result is uncontrolled hypertension
and signs of heart failure
In your opinion What are
the fallacies done in this case?

8. Life style pitfals
• Fluid restriction
• Sodium restriction to not more than 2gm/day equivalent to 5 gm
table salt per day
• Inter dialysis Weight gain that must not exceed 0.8 kg/ day

9. Nephrologist
• dialysis should be at least three times a week
• total duration should be at least 12 hours per week
• Increase in treatment time and or frequency should be considered
in resistant hypertension
• Daily sessions if feasible helps in reducing BP
• Nocturnal session found to better control BP with less medications
• Special protocol for ultrafiltration of more fluid and usage of less
intradialytic sodium must be acquired
EBPG guideline on dialysis strategies. Nephrol Dial
Transplant 22 [Suppl 2]: ii5–ii21, 2007

10. The goal is to reach a Dry Weight
• Criteria to determining DW:
oNo marked fall in BP during dialysis.
oNo hypertension (predialysis BP at the beginning of the week <140/90
mm Hg).
oNo peripheral edema.
oNo pulmonary congestion on chest X-ray.
oCardiothoracic ratio ≤50% (≤53% in females).

11. Primary health care physician
• He did not set a life style modification program to the patient
• He did not offer him a weight reduction program to improve his blood
pressure via weight reduction
• No investigations were requested for secondary hypertension
specially Reno vascular hypertension

12. • Blood pressure monitoring :
oIts not accurate to depend on one office reading of blood pressure
oBP variation in dialysis patient is very common
oPredialysis reading over estimate mean BP by 10 mmHg
oPost dialysis reading under estimate the mean BP by 7 mmHG
oThe best way is either Ambulatory blood pressure monitoring or
home blood pressure readings
oA morning and an evening home readings are ideal to monitor blood
pressure
Primary health care physician

13. • The treatment choice :
o ACE inhibitors and ARBS are the groups of choice for patients with HD They also reduce
LV mass and reduces mortality
o Beta blockers are very important in hypertensive patients with dialysis as they tends to
improve mortality
o Calcium channel blockers specially Dyhydropiridines are
effective for overhydrated state commonly observed in HD patients although there is
scanty data about their mortality benefit
o There is no role for diuretics in treating patients with ESRD specially if they are anuric
o High intensity statin therapy must be taken into consideration in such patients with
cardiovascular risk and dyslipidemia
Primary health care physician

14. •Effect of dialysis on antihypertensive
drugs:

15. Pharmacokinetic properties of ACE Inhibitors in ESRD
T1/2(h)
normal
T1/2(h)
ESRD
Initial
dose in
HD
Maintenance
dose in HD
Removal
during HD
Captopril 2-3 20-30 12.5 q24h 25-50 q24h Yes
Enalapril 11 prolonged 2.5 q24h
or q48h
2.5-10 q24h
or q48h
Yes
Fosinopril 12 prolonged 10 q24h 10-20 q24h Yes
Lisinopril 13 54 2.5 q24h
or q48h
2.5-10 q24h
or q48h
Yes
Ramipril 11 prolonged 2.5-5q24h 2.5-10 q24h yes
Henrich W. Principles and Practice of Dialysis

16. Pharmacokinetic properties of ARB’s in ESRD
T1/2(h)
normal
T1/2(h)
ESRD
Initial dose
in HD
Maintenance
dose in HD
Removal
during HD
Candesartan 9 ? 4 q24h 8-32 q24h No
Irbesartan 11-15 11-15 75-150 q24h 150-300 q24h No
Losartan 2 4 50 q24h 50-100 q24h No
Telmisartan 24 ? 40 q24h 20-80 q24h No
Valsartan 6 ? 80 q24h 80-160 q24h No
Henrich W. Principles and Practice of Dialysis

17. Pharmacologic properties of β-blockers in chronic dialysis patients
T1/2(h)
normal
T1/2(h)
ESRD
Initial dose
in HD
Maintenance
dose in HD
Removal
during HD
Acebutolol 3.5 3.5 200 q24h 200-300 q24h yes
Atenolol 6-9 <120 25 q48h 25-50 q48h Yes
Carvedilol 4-7 4-7 5 q24h 5 q24h no
Metoprolol 3-4 3-4 50 b.i.d. 50-100 b.i.d. high
Propranolol 2-4 2-4 40 b.i.d. 40-80 b.i.d. yes
Henrich W. Principles and Practice of Dialysis

18. Blood pressure remaining above goal in spite of
concurrent use of 3 antihypertensive agents of
different classes.
Resistant Hypertension

19. Resistant Hypertension you must search for
• The use of non steroidal anti-inflammatory drugs
• Renovascular hypertension
• Increasing cysts in polysystic kidney disease
• Concomitant use of erythropoietin therapy
• Presence of sleep breathing disorders
• Compliance

20. Drugs that can be used in addition
• Transdermal clonidine at weekly intervals.
• Minoxidil, a potent vasodilator used with beta blockers
Use of transdermal clonidine in chronic hemodialysis patients. Clin Nephrol 1993;39:32-36
Use of minoxidil in the azotemic patient. J Cardiovasc Pharmacol 1980;2:173-S180

21. Resistant HTN in ESRD
• Renal sympathetic nerve ablation
• Device-Based Therapy for Resistant Hypertension
• Baroreflex Activation Therapy
• Renal Denervation Therapy

22. Baroreflex Activation Therapy (BAT)
Continuously Modulates the Autonomic Nervous
System
Carotid
Baroreceptor
Stimulation
Heart Vessels Kidney
Inhibit
sympathetic &
Enhance Parasymp
HR Vasodilation Natriuresis
Renin
secretion

23. Anatomical Location of Renal
Sympathetic Nerves
• Arise from T10-L1
• Follow the renal artery
to the kidney
• Primarily lie within the
adventitia
The Journal of Clinical Hypertension. 14, pages 799–801,2012
Circulation. 2002;106:1974–1979

24. • appears at the end of dialysis when water removal is completed.
• Pathogenesis and therapy are not well documented.
oUltrafiltration
oHypovolemia
opre-existing hypertension
oHypercalcemia
oImprovement of hypoxia
oantihypertensives that are remove during dialysis.
Paradoxical hypertension

25. So what we did was:
• We advised the patient about life style and diet habits
• We modify the protocols of dialysis including frequency, duration and
the amount of sodium
• We offered the patient a new regime for drug therapy stressing upon
patient compliance
• We rained the patient for home readings

26. Aggressive Treatment
oValsartan 160 mg o.d
oAmlodipine 10 mg o.d
oCarvidilol 25 mg o.d
oAtorvastatin 40 mg o.d
We achieved a goal of 110/70 blood pressure
Is it an optimum goal for mortality benefit ?

27. U shape mortality relation ship
• This means that the lower BP is not the better in terms of mortality
benefits
• Among 16,959 dialysis patients in the US, low SBP (120mmHg) was
associzated with increased mortality among HD patient
• High SBP (150mmHg) was associated with increased mortality among
patients who survived at least 3 years.
Changing relationship of blood pressure with mortality
over time among hemodialysis patients. J
Am Soc Nephrol 17: 513–520, 2006

28. Relationship between BP and mortality in dialysis patients
Zagers’ 1998 reference

29. In conclusion
• Patient with resistant hypertension and HD needs very special care
• Volume restriction and dietary sodium reduction are of most important
• Achieving proper dry weight is very important
• The choice of drugs must be tailored upon patient
• Special care must be taken upon the effect of dialysis upon the
antihypertensive drugs
• Too low blood pressure is as harmful as too high blood pressure

30. Thank
you