Dialysis Hypotension: A Role for Inadequate Increase in Arginine Vasopressin Levels? A Systematic Literature Review and Meta-Analysis

Weng²,

et al. 2016

Medicine

To investigate the risk of nonarteritic anterior ischemic optic neuropathy (NAION) following end-stage renal disease (ESRD).A retrospective, nationwide, matched cohort study.ESRD patients identified by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 585.The study cohort included 93,804 ESRD patients registered with the Taiwan National Health Insurance Research Database between January 2000 and December 2009. An age- and sex-matched control group comprised 93,804 patients (case:control = 1:1) selected from the Taiwan Longitudinal Health Insurance Database 2000. Information for each patient was collected from the index date until December 2011. The incidence and risk of NAION were compared between the ESRD and control groups. The adjusted hazard ratio (HR) for NAION after adjustment for potential confounders was obtained by a Cox proportional hazard regression analysis. A Kaplan–Meier analysis was used to calculate the cumulative incidence rate of NAION.The incidence of NAION following ESRD.In total, 133 ESRD patients (0.14%) and 51 controls (0.05%) had NAION (P < 0.001) during the follow-up period, leading to a significantly elevated risk of NAION in the ESRD patients compared with the controls (incidence rate ratio = 3.14, 95% confidence interval [CI] = 2.11–4.67). After adjustment for potential confounders including diabetes mellitus, hypertension, hypotension, hyperlipidemia, and 2-way interaction terms between any 2 factors, ESRD patients were 3.12 times more likely to develop NAION than non-ESRD patients in the full cohort (adjusted HR = 3.12, 95% CI = 2.10–4.64). Additionally, patients with hypertension and hyperlipidemia showed higher incidence rates of NAION in the ESRD group compared with the controls: 2.31 (95% CI = 1.40–3.82) for hypertension and 2.72 (95% CI = 1.14–6.50) for hyperlipidemia.ESRD increased the risk of NAION, which is an interdisciplinary emergency. Close collaboration between nephrologists and ophthalmologists is important in NAION management following ESRD to prevent fellow eye involvement.

Section: Discussionmentioning

confidence: 99%

Risk of Nonarteritic Anterior Ischemic Optic Neuropathy Following End-Stage Renal Disease

Weng²,

et al. 2016

Medicine

“…Of particular interest is arginine vasopressin, which has potent vasoconstrictor effects via its action on V1a receptors in the vasculature. Under normal conditions arginine vasopressin is stimulated by increases in plasma osmolality and significant hypovolemia; however, these responses appear to be blunted in hypotension-prone patients on hemodialysis (44). Indeed, we previously reported that higher predialysis calculated osmolarity is associated with greater decline in intradialytic BP (4), whereas others have reported on the benefit of infusing vasopressin for the prevention of IDH (44).…”

Section: Arteriolar Vasoconstrictionmentioning

confidence: 99%

Mechanisms, Clinical Implications, and Treatment of Intradialytic Hypotension

Reeves

Causland

2018

CJASN

126

112

Individuals with ESKD requiring maintenance hemodialysis face a unique hemodynamic challenge, typically on a thrice-weekly basis. In an effort to achieve some degree of euvolemia, ultrafiltration goals often involve removal of the equivalent of an entire plasma volume. Maintenance of adequate end-organ perfusion in this setting is dependent on the institution of a variety of complex compensatory mechanisms. Unfortunately, secondary to a myriad of patient- and dialysis-related factors, this compensation often falls short and results in intradialytic hypotension. Physicians and patients have developed a greater appreciation for the breadth of adverse outcomes associated with intradialytic hypotension, including higher cardiovascular and all-cause mortality. In this review, we summarize the evidence for adverse outcomes associated with intradialytic hypotension, explore the underlying pathophysiology, and use this as a basis to introduce potential strategies for its prevention and treatment.

“…There are several studies evaluating adequacy and levels of AVP in IDH. Ettema et al also published a meta‐analysis including these studies and determined that there is a little or no increase in AVP during HD sessions in patients with IDH and mentioned that a blunt response could be the one of the pathophysiogical issues in IDH . A possible deficiency of AVP response in IDH also led trials of replacement therapies.…”

Section: Discussionmentioning

confidence: 99%

Low Copeptin Levels in Patients With Intradialytic Hypotension

et al. 2019

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.