This document discusses changes in blood pressure that occur during and after hemodialysis. It explains that hemodialysis aims to remove fluid and solutes from the body to achieve "dry weight" through diffusion and convection. Both hypotension and hypertension can occur, and the document outlines their causes and various prevention and treatment strategies. These include carefully setting the fluid removal rate, using bicarbonate dialysate, and choosing appropriate antihypertensive medications. The document emphasizes the complexity of blood pressure fluctuations during dialysis and the need for effective management to ensure patient safety.
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Causes of hypotension during dialysis by aniqa attaaniqaatta1
title; hypotension and causes of hypotension
this lecture will cover the hemodialysis related hypotension and causes of hypotension during dialysis. like cardiac related factors, idh related volume changes..
Note of management acute heart failure
Initially I just read the ESC 2016 guideline and was interested in choosing inotropic agents. I started to reads books and looked for more information.
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10. Goals of Dialysis
–Solute clearance
• Diffusive transport (based on countercurrent
flow of blood and dialysate)
• Convective transport (solvent drag with
ultrafiltration)
–Fluid removal
13. Appropriate Removal Rate
setting the fluid removal rate to not exceed
the plasma refill rate (PRR) will minimize
risk of hypovolemia, hypotension
“Never too fast, never too much”
Vascular
Space
Plasma
Refill
Rate
Intravascular
Hemodialysis
UF rate
Extravascular
UFR ≤ PRR
(UFR)UltrafiltrationRemoval byFluid
illicits compensatory mechanisms, termed
plasma or intravascular refill, aimed at
minimizing this reduction
14. Dialysate Buffer
• Acetate: in the early 1960s became the
standard dialysate buffer used to correct
uremic acidosis
In the mid 1980s some reported the linking
between acetate and cardiovascular
instability and hypotension during HD
• Bicarbonate: emerged the buffer of choice
15. Dialysis Solution Sodium Level
Plus Minus
Low
dialysate
sodium
Less weight-gain,
thirst
&hypertension
More hypotension,
cramps
High
dialysate
sodium
Less hypotension,
cramps
More weight gain,
thirst
& hypertension
16. EXCESS FLUID WEIGHT
Body weight at which composition of
body fluid compartments is normal.
At higher weights there is expansion
of compartments
At lower weights there is depletion
of compartments.
Both these states have adverse
clincal consequences.
CONCEPT of DRY WEIGHT
DRY WEIGHT
(euvolemia)
17. In short, among all these elements, the 2 essential
clues are the BP and the weight
24. Acute management of low blood pressure
associated with hemodialysis
Ultrafiltration should either be stopped or the
rate decreased.
The patient should be placed in the
Trendelenburg position.
The blood flow rate should be reduced.
Intravascular volume may be replaced with
mannitol or saline. Currently the use of an
intravenous bolus of saline is the first-line
therapy for hypotension.
25. PREVENTION
• Accurate setting of the "dry weight"
• Steady, constant ultrafiltration
• Increased dialysate sodium concentration and
sodium modeling
• Bicarbonate dialysate buffer
• Decrease dialysate temperature from 37C to
34-35C
26. Prevention – Con’t
Improvement in cardiovascular Performance in
cardiac patients.
Midodrine (the selective alpha-1 adrenergic
agonist) in patients with autonomic neuropathy and
perhaps others with severe hemodialysis
hypotension not responsive to the above measures.
Avoidance of food.
Avoid large interdialytic weight gain
No antihypertensive before dialysis
28. Intradialytic Hypertension
Clinical Definitions
• ↑MAP of ≥ 15 mmHg during or
immediately post dialysis
• Hypertension during 2nd or 3rd hr
of HD after significant UF removed
• ↑BP that is resistant to UF
29. The Etiopathogenesis of Intradialytic Hypertension
Hypervolemia
Sodium balance positive and extracellular volume expand
Increased systemic vascular resistance
Increased sympathetic activity
Renin-angiotensin system hyperactivity
Endothelial cell dysfunction
Elevated concentration of endothelin 1
Calcification of the arterial tree
Increased hematocrit
Erythropoietin Therapy
Increased vascular stiffness
Nitric oxide deficiency
30. Hypertension in dialysis
(Another World
• There are limited studies on controlling blood
pressure in patients on dialysis.
• No consistent guidelines available due to the
fact that no one knows what blood pressure to
target.
– Pre, Post, intradialytic, non-dialysis day.
31. Blood pressure measurement
in dialysis patients
Majority of Uremic patients lack diurnal variation in BP
Immediate pre‐dialysis and post‐dialysis are misleading and not
reflective of true interdialytic BP
However, a post dialytic BP is more reflective of interdialytic BP
*Continuous monitoring is warranted in poor control patients
(those with large interdialytic weight gain)
*“Systolic load “ ‐‐ > amount of time SBP exceeds 140 mmHg per
day as correlates to incidence of LVH
33. Treatment of hypertension in
patients on hemodialysis
Treatment of hypertension is often a multiple-step,
multidisciplinary process to reach KDOQI guidelines
of predialysis BP values of <140/90 mm Hg.
The key to successful treatment is patience; it often
takes 4-6 weeks to achieve results.
(This represents the lag phenomenon )
34. Chronic
volume
expansion
Vascular Na/K
ATPase
NO Synthetase
ADMA
DLIS etc
NO
iCa++
Vaso-
constriction
Sustained UF & Na restriction
ECV
DLIS etc
ADMA
LAG
BP
Lag period between normalisation of
ECF and optimal control of BP
DLIS:digoxin-like immunoreactive substance ADMA:asymmetric-dimethyl arginine
38. Choice of antihypertensive drugs
All classes of antihypertensive drugs can be used
in dialysis patients, with the sole exception of
diuretics, which are not commonly used because
of their lack of efficacy.
Therefore, with the exceptions of diuretics, the
criteria for drug selection are quite similar to
those used in non-dialysis patients.
39. Dialysis Clearance of Drugs
In general, removal of drugs on HD has NOT
been tested and is based on theoretical
considerations of molecular size and chemical
makeup of the drug
Drugs with low MW, limited volume of
distribution (Vd) , and that are water-soluble are
most likely to be removed by HD and will require
extra dosing
40. Postdialysis dosing or extra doses after HD may
be necessary for certain antihypertensive agents:
•Angiotensin converting enzyme inhibitors (ACE-I): all are
dialyzable except fosinopril
•Angiotensin receptor blockers (ARB): none are dialyzed
•B-blockers: atenolol and metoprolol are dialyzable but
labetolol and carvedilol are not
•Calcium channel blocker: amlodipine is not dialyzable
42. Intradialytic Blood Pressure Fluctuations
• Current State
Clinically significant alteration in blood pressures
is one of the biggest challenges encountered in
the dialysis unit
• Ideal State
Clinicians understand the physiological changes
in blood pressures during hemodialysis and
prevent and manage these changes effectively to
ensure patient’s safety
43. Thank you for your attention
Gracias por su atención
Danke für Ihre Aufmerksamkeit
Go raibh maith agat
Grazie per l´Attenzione
AAp sAAb kA shukriyA…
Merci pour votre attention
