Hypertension in the hemodialysis patient and the “lag phenomenon”: insights into pathophysiology and clinical management

Khosla, Uday M.; Johnson, Richard J.

doi:10.1053/j.ajkd.2003.12.036

Cited by 44 publications

(38 citation statements)

References 108 publications

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“…Nevertheless, this rate is still higher than the recommended salt restriction for essential hypertension [20]. It should be noted that the effect of weight reduction or correction of volume excess on blood pressure appears slowly due to a ‘lag phenomenon’ [26]. …”

Section: Discussionmentioning

confidence: 99%

Higher Survival Rates of Chronic Hemodialysis Patients on Anti-Hypertensive Drugs

Iseki

Tanaka²,

Nakai³

et al. 2009

Nephron Clin Pract

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Background: The effects of anti-hypertensive drugs on survival have not been examined in a large cohort of hemodialysis (HD) patients. Methods: We examined the relationship between blood pressure, anti-hypertensive drug therapy, and survival using the nationwide HD registry of the Japanese Society for Dialysis Therapy. Outcomes were confirmed using the coded ID numbers of the 2005 and 2006 registries. Logistic analyses were performed to determine the effect of anti-hypertensive drug therapy on survival. Results: A total of 163,668 patients (50.6% men; 31.5% with diabetes mellitus; mean age 63.6 years) on HD 3 times a week in 2005 were studied. Mean (SD) levels of systolic and diastolic blood pressure were 153.4 (24.1) and 78.7 (13.7) mm Hg, respectively, before the HD session. Two-thirds of the HD patients were prescribed anti-hypertensive drugs and the numbers of anti-hypertensive medications were: 1 in 26.8%, 2 in 24.4%, and 3 or more in 14.5% of the total patients. The 1-year mortality rate was 6.6% overall: 8.5% in patients not prescribed anti-hypertensive drugs and 5.6% among those prescribed anti-hypertensive drugs. The odds ratio (95% confidence interval) for the 1-year mortality rate was 0.724 (0.681–0.770, p < 0.0001) for patients prescribed anti-hypertensive drugs, after adjusting for age, sex, diabetes mellitus, body mass index, HD duration, serum albumin, and systolic blood pressure. Conclusion: Survival was better in patients prescribed anti-hypertensive drugs, particularly renin-angiotensin system inhibitors, than in those not prescribed anti-hypertensive drugs. The causality on this association remained to be determined and prospective studies on blood pressure target levels and the effects of anti-hypertensive drug class in HD patients are warranted.

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Section: Discussionmentioning

confidence: 99%

Higher Survival Rates of Chronic Hemodialysis Patients on Anti-Hypertensive Drugs

Iseki

Tanaka²,

Nakai³

et al. 2009

Nephron Clin Pract

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“…12,13 However, inadequate removal of fluid may lead to a longterm increase in cardiac output, compensatory increase in systemic vascular resistance, and hypertension. 8,14,15 In turn, this can lead to cardiovascular morbidity and mortality. 16 Epidemiological studies suggested that expanded extracellular fluid volume in hemodialysis patients was associated with increased all-cause mortality.…”

Section: -11mentioning

confidence: 99%

“…7 An accurate prescription can improve tolerance and adherence to dialysis therapy and avoid the long-term consequences of volume excess. 8 Clinical experience suggests that keeping the patient "too wet" may lead to poor long-term outcomes, and "too dry," to poor tolerance. A fluid removal rate that exceeds the refilling rate of the intravascular volume may result in hypotension, which continues to be a vexing problem for which new therapies are being developed.…”

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confidence: 99%

Diagnostic Utility of Blood Volume Monitoring in Hemodialysis Patients

Agarwal

Kelley

Light

2008

American Journal of Kidney Diseases

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Background: Assessment of volume state is difficult in hemodialysis patients. Whether continuous blood volume monitoring can improve the assessment of volume state is unclear.Study Design: Diagnostic test study. Settings & Participants: Asymptomatic long-term hemodialysis patients (n ϭ 150) in 4 universityaffiliated hemodialysis units.Index Tests: Ultrafiltration rate (UFR) divided by postdialysis weight (UFR index), slopes of relative blood volume (RBV), RBV slope corrected for UFR and weight (volume index).Reference Tests: Dialysis-related symptoms and echocardiographic signs of volume excess and volume depletion, assessed by using inferior vena cava (IVC) diameter after dialysis and its collapse on inspiration. Volume excess was defined as values in the upper third of IVC diameter or lower third of IVC collapse on inspiration. Volume depletion was defined as values in the lower third of IVC diameter or upper third of IVC collapse on inspiration.Results: Mean UFR was 8.3 Ϯ 3.8 (SD) mL/h/kg. Mean RBV slope was Ϫ2.32% Ϯ 1.50%/h. Mean volume index was Ϫ0.25% Ϯ 0.17%/h/mL/h ultrafiltration/kg. Volume index provided the best fit of observed RBV slopes. Volume index was related to dizziness, the need to decrease UFR, and placement in Trendelenberg position. RBV and volume index, but not UFR index, were related to echocardiographic markers of volume excess and depletion. Areas under the receiver operating characteristic curve to predict volume excess were 0.48 (95% confidence interval [CI], 0.33 to 0.63) for UFR index, 0.71 (95% CI, 0.60 to 0.83) for RBV slope, and 0.73 (95% CI, 0.59 to 0.86) for volume index. Areas under the receiver operating characteristic curve to predict volume depletion were 0.56 (95% CI, 0.38 to 0.74) for UFR index, 0.55 (95% CI, 0.38 to 0.72) for RBV slope, and 0.62 (95% CI, 0.48 to 0.76) for volume index.Limitations: Dialysis-related symptoms and echocardiographic findings are not validated measures of volume. Our results were not adjusted for demographic or clinical characteristics; performance characteristics of the indices may differ across populations.Conclusions: Volume index appears to be a novel marker of volume, but requires validation studies, and its utility needs to be tested in clinical trials. Am J Kidney Dis 51:242-254.

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“…According to the US Renal Data System (2008-2009), the adjusted cardiovascular hospitalization rate is 0.55 per patient-year. Most of these episodes are congestive heart failure, and the majority is attributable to volume overload (4)(5)(6).…”

Section: Introductionmentioning

confidence: 99%

Determinants and Short-Term Reproducibility of Relative Plasma Volume Slopes during Hemodialysis

Anand

Sinha

Agarwal

2012

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives Hypervolemia is a major cause of morbidity, in part because of the lack of well characterized diagnostic tests. The hypothesis was that relative plasma volume (RPV) slopes are influenced by ultrafiltration rate, directly associate with improvement in arterial oxygen saturation, and are reproducible.Design, setting, participants, & measurements RPV slopes were measured on three consecutive hemodialysis sessions. Various relationships were tested using mixed models. Reproducibility was assessed by the intraclass correlation coefficient.Results RPV slopes averaged 1.3761.45% per hour. The mean RPV slopes were steeper on the first dialysis of the week, which correlated with a higher ultrafiltration rate; RPV slope and ultrafiltration rate were directly related. Increasing ultrafiltration rate quartiles were associated with similar change in RPV in the first 1 hour of dialysis but steeper changes in RPV subsequently. A direct relationship emerged between increasing RPV slopes and increasing arterial oxygen saturation slopes. The intraclass correlation coefficient for the relative plasma volume slope was 0.77.Conclusions Although ultrafiltration rate is a major determinant of RPV slope, similar ultrafiltration rates are associated with varying RPV between individuals. Because RPV is associated with little change by ultrafiltration rate during the first 1 hour of dialysis, probing dry weight during the earlier part of dialysis may be safer. RPV slopes are physiologically meaningful, because they are associated with parallel changes in arterial oxygenation saturation slopes. RPV slopes are reproducible, and therefore, RPV may serve as a useful marker to judge changes in volume status within an individual.

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Hypertension in the hemodialysis patient and the “lag phenomenon”: insights into pathophysiology and clinical management

Cited by 44 publications

References 108 publications

Higher Survival Rates of Chronic Hemodialysis Patients on Anti-Hypertensive Drugs

Higher Survival Rates of Chronic Hemodialysis Patients on Anti-Hypertensive Drugs

Diagnostic Utility of Blood Volume Monitoring in Hemodialysis Patients

Determinants and Short-Term Reproducibility of Relative Plasma Volume Slopes during Hemodialysis

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