20% incidence of intra-dialytic hypotension is widely cited . incidence in cohort studies varies between 6% and 27% . In the largest cohort reported so far, 10% of patients had frequent hypotensive episodes whereas 13%occasionally had hypotensive episodes
No universally accepted definition EEBPG working group stresses that both a reduction in BP, as well as clinical symptoms with need for nursing intervention should be present. A proposed definition is a decrease in › systolic BP 20mmHg › a decrease in mean arterial pressure (MAP) by 10mmHg › associated with clinical events and need for nursing interventions.
IDH , a putative causal role in myocardial and cerebral ischemia. Independent and negative predictor of long-term fistula outcome Causative role in adverse outcome or is merely a marker of co morbid conditions, which increase the sensitivity for IDH. Impair solute clearance, due to compartmentalization of blood volume and premature termination of dialysis sessions
Age, female Gender, Presence of diabetes mellitus, Hyperphosphataemia, Presence of coronary artery disease, Renal diagnosis other than glomerulonephritis use of nitrates
Interplay of 04 factors1. Ultra-filtration2. Refill blood volume3. Dialysate –Na+,Ca++,Temp4. Patient sensitivity to volume withdrawn
Autonomic neuropathy, which canbe assessed using standardized function. Bradycardia,so called Bezold-Jarish reflex observed during IDH episodes. Induction of cytokines, bioincompatibility of the dialysis membrane, the use of acetate as dialysate buffer.
Hydration of Patient Dry Weight Radiological Inv., CT Ratio, IVC diameter Multi frequency Bio-impedance BNP level ,Cyclic GMP
Checking of Heart rate Blood pressure Patient alarm
Pulsed Ultrafiltration…increases IDH. IntraDialytic Blood Volume monitoring Perfusion state ,Oxygenation and anti- coagulation Milieu
Na+>> or equal 144mEq less chances Bicarbonate Ca++ low dialysate Mg++ low <.25 mMoL
Bio-Compatibility Reuse of incompletely treated Inadequately washed
Temperature primer defect Low temp can be used in cases of IDH .5 degree cent be reduced every 15-30 min(Never less than 35 Degree centigrade)
Ultrafiltration Followed by Isovolumic Dialysis ……Not Rcommended
Less common with slow ultra filtration. Ultrafiltration rate-<10ml/Kg/Hr Pt with 8hrs dialysis ,thrice a week <1% Saran R, Bragg-Gresham JL, Levin NW et al. Longer treatment time and slower ultrafiltration in hemodialysis: associations with reduced mortality in the DOPPS. Kidney Int 2006; 69:1222–1228
Avoidance of antihypertensive drugs and prescription of vasoactive medication Antihypertensives ..Ca Channel blockers Nitrates …independent factor.
Midodrine is an oral alpha-1 agonist. Its metabolite midodrine,desglymidodrine, induces constriction of both resistance and capacitance vessels. Dose 2.5 to 10mg 30 min before Dialysis Side effects-scalp parestehesias, heartburn, flushing, headach e, neck pain and weakness.
Lysine vasopressine, Ergotamine, Methylene blue Dobutamine Insufficient data to make recommendation
L-carnitine levels low. Because of reduced biosynthesis in the kidney and losses in the dialysate. Improves Systolic function Improved LVEF noted with supplementation A study n-223..low IDH After Dialyisis-20mg/Kg be given
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.
Try objective methods to assess dry weight. Perform cardiac evaluation. Gradual reduction of dialysate temperature from 36.8 Deg C downward (lowest 35 Deg.C)
Consider individualized blood volume controlled feedback. Prolong dialysis time and/or increase dialysis frequency. Prescribe a dialysate calcium concentration of 1.50 mmol/l. Mg Concentration .25 mmol/L