Intra Dialytic Hypotension

Dr(Lt Col)Ashutosh OjhaStudent ,Post Doctoral Certificate

(Nephrology)GMCH,Guwahati

European Guidelines 2007

Nephrology Dialysis, Transplant (2007) 22 [Suppl 2]:

Plan

Incidence Definition Significance Patho-physiology Prevention Treatment

Intra-Dialytic Hypotension…….Incidence

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

Intra-Dialytic Hypotension…….Definition 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

nursinginterventions.

Intra-Dialytic Hypotension…….Significance

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

Intra-Dialytic Hypotension…….Etiology

Age, female Gender, Presence of diabetes mellitus, Hyperphosphataemia, Presence of coronary artery disease, Renal diagnosis other than

glomerulonephritis use of nitrates

Intra-Dialytic Hypotension…….patho-physiology

Interplay of 04 factors1. Ultra-filtration2. Refill blood volume3. Dialysate –Na+,Ca++,Temp4. Patient sensitivity to volume

withdrawn

IDH…….pathophysiology…..contd

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.

IDH…….Prevention…..Assessment

Hydration of Patient Dry Weight Radiological Inv., CT Ratio, IVC

diameter Multi frequency Bio-impedance BNP level ,Cyclic GMP

IDH…….Prevention…..Assessment

Checking of Heart rate

Blood pressure

Patient alarm

IDH…….Prevention…..Assessment

Cardiac Evaluation Diastolic dysfunction Ejection Fraction Ischemia assessment Pericardium assessment

IDH…….Prevention…..Life styles

Dietary Salt Food intake –Pre Dialysis During Dialysis …..??? Caffiene …No Benefit

IDH………Prevention …Ultra Filtration

Pulsed Ultrafiltration…increases IDH.

IntraDialytic Blood Volume monitoring

Perfusion state ,Oxygenation and anti-coagulation Milieu

IDH………Dialysate

Na+>> or equal 144mEq less chances Bicarbonate

Ca++ low dialysate

Mg++ low <.25 mMoL

IDH………Dialyser

Bio-Compatibility

Reuse of incompletely treated

Inadequately washed

IDH………Dialysate Temperature

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)

IDH………Prevention

Ultrafiltration Followed by Isovolumic Dialysis ……Not Rcommended

IDH………Dialysis Duration

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

IDH………Pharmacotherapyassociation

Avoidance of antihypertensive drugs and prescription of vasoactive medication

Antihypertensives ..Ca Channel blockers

Nitrates …independent factor.

IDH………Pharmacotherapy

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, headache, neck pain and weakness.

IDH………Drug Tried

Lysine vasopressine, Ergotamine, Methylene blue Dobutamine

Insufficient data to make recommendation

IDH………Levo carnitine

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

IDH………Prevention protocol.1st line

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.

IDH………Prevention protocol.2nd line

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)

IDH………Prevention protocol.2nd line

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

IDH………Prevention protocol.3rd line

Consider midodrine. Consider L-carnitine supplementation. Consider peritoneal dialysis.

IDH………Treatment Protocol

Trendelenburg position Stopping ultrafiltration Infusion fluids

IDH………Infusion

Blood Best Colloid Next Not available ..Crystalliod…

Crystalliod –Dextrose 25%<10% Saline 3%< NS

IDH………Last resort

Peritoneal Dialysis

Artificial Kidney

IDH………Humble Thanks

Shri B N Bordoloi…….Art of Dialysis

Faculty….Science of Nephrology

Dr P J Mahanta ,DM(Nephro) Assistant Prof for entrusting me this seminar

Thank You Madam & Sir