Pediatric intradialytic hypotension: recommendations from the Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup

Abstract

Intradialytic hypotension (IDH) is a common adverse event resulting in premature interruption of hemodialysis, and consequently, inadequate fluid and solute removal. IDH occurs in response to the reduction in blood volume during ultrafiltration and subsequent poor compensatory mechanisms due to abnormal cardiac function or autonomic or baroreceptor failure. Pediatric patients are inherently at risk for IDH due to the added difficulty of determining and attaining an accurate dry weight. While frequent blood pressure monitoring, dialysate sodium profiling, ultrafiltration guided blood volume monitoring, dialysate cooling, hemodiafiltration, and intradialytic mannitol and midodrine have been used to prevent IDH, they have not been extensively studied in pediatric population. Lack of large-scale studies on IDH in children makes it difficult to develop evidence based management guidelines. Here we aim to review IDH preventative strategies in the pediatric population and outlay recommendations from the Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup. Without strong evidence in the literature, our recommendations from the expert panel reflect expert opinion and serves as a valuable guide.

Implementing a fluid volume management program to decrease intra-dialytic hypotensive events in a paediatric in-centre haemodialysis unit: a quality improvement project

“…The number of IDH events per number of HD sessions (expressed as a percentage) per week was selected as the primary outcome measure of this project. IDH events were defined according to recent consensus guidelines [ 1 ] by intra-dialytic systolic blood pressure < 5th percentile for age and/or symptoms (e.g. abdominal pain, nausea, vomiting, muscle cramps, restlessness, light-headedness, syncope or anxiety) triggering a fluid bolus administration or cessation of ultrafiltration.…”

“…Intra-dialytic hypotension (IDH) is a serious and pervasive adverse event of haemodialysis procedures, defined by the Paediatric Continuous Renal Replacement Therapy working group [ 1 ] as the combination of systolic blood pressure below the 5th percentile for age and/or clinical symptoms, such as abdominal pain, nausea, vomiting, muscle cramps, restlessness, light-headedness, syncope or anxiety. IDH occurs in 9–30% of paediatric haemodialysis sessions [ 1 , 2 ].…”

“…Intra-dialytic hypotension (IDH) is a serious and pervasive adverse event of haemodialysis procedures, defined by the Paediatric Continuous Renal Replacement Therapy working group [ 1 ] as the combination of systolic blood pressure below the 5th percentile for age and/or clinical symptoms, such as abdominal pain, nausea, vomiting, muscle cramps, restlessness, light-headedness, syncope or anxiety. IDH occurs in 9–30% of paediatric haemodialysis sessions [ 1 , 2 ]. The major aetiological factor triggering IDH is intravascular volume depletion due to excessive ultrafiltration, likely in association with poor compensatory mechanisms such as abnormal cardiac function and autonomic failure [ 3 – 7 ].…”

“…Observational studies in adult patients on haemodialysis suggest that patients experiencing repeated IDH events are at risk for significant long-term cardiovascular morbidity and all-cause mortality [ 8 – 12 ], including myocardial infarction, reduced left ventricular ejection fraction, hospitalization, arteriovenous fistula thrombosis, intra-dialytic cerebral ischemia and decreased residual kidney function [ 8 , 11 , 13 – 16 ]. While prospective clinical outcome data in children are lacking, minimizing the magnitude and frequency of IDH is a priority for haemodialysis providers [ 1 ].…”

Intradialytic Hypotension and Mortality in Adolescents and Young Adults With Kidney Failure Receiving Maintenance Hemodialysis

“…The Pediatric Continuous Renal Replacement Therapy Workgroup defined IDH as systolic blood pressure (SBP) less than the fifth percentile adjusted for age and sex with associated clinical symptoms, such as abdominal pain, nausea, vomiting, muscle cramps, restlessness, light headedness, syncope, and anxiety. 6 However, information on clinical symptoms and interventions performed during HD is often limited, so IDH is also sometimes defined solely by SBP less than the fifth percentile. 7 , 8 , 9 Other definitions include SBP less than the 50th percentile, 10 a 20- or 30-mm Hg drop from predialysis SBP, 11 , 12 nadir intradialytic SBP below 90 or 100 mm Hg, 13 , 14 and combination definitions, such as nadir intradialytic SBP less than 90 mm Hg accompanied with a 20- or 30-mm Hg drop from the patient’s predialysis SBP.…”