The prevalence of persistent intradialytic hypertension in a hemodialysis population with extended follow-up

Buren, Peter Noel Van; Kim, Catherine; Toto, Robert D.; Inrig, Jula K.

doi:10.5301/ijao.5000126

Cited by 46 publications

(53 citation statements)

References 13 publications

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“…We previously showed that an increase in systolic BP ≥10 mmHg from pre- to post-dialysis occurred at least once in almost all patients in a 350 patient cohort followed for six months, and we have also defined the expected frequency for IH to occur within a dialysis population [6]. Our IH patients in this study (systolic BP increase of at least 10 mmHg from pre- to post-hemodialysis in >40% of treatments over prior 6 months) experienced IH as frequently as the 80 th –90 th percentile from our prior study [6]; and our controls in this study (systolic BP increase of at least 10 mmHg from pre- to post-hemodialysis in 11% of treatments over prior 6 months) experienced IH as frequently as the 25 th –30 th percentile from our prior study [6]. Our current study’s methodology clearly minimizes the risk of misclassification bias and is highly applicable to patients with recurrent IH.…”

Section: Discussionmentioning

confidence: 99%

“…Most hemodialysis patients experience IH in a small percentage of their dialysis treatments, but IH is a persistent and recurrent phenomenon in some hemodialysis patients [6]. Understanding the pathophysiology of IH is important because patients with recurrent IH have higher ambulatory BP burden [7, 8] and increased risk for morbidity and mortality [5, 9–11].…”

Section: Introductionmentioning

confidence: 99%

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Extracellular Volume Overload and Increased Vasoconstriction in Patients With Recurrent Intradialytic Hypertension

Buren

Zhou

Neyra

et al. 2016

Kidney Blood Press Res

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Background/Aims: Intradialytic hypertension (IH) occurs frequently in some hemodialysis patients and increases mortality risk. We simultaneously compared pre-dialysis, post-dialysis and changes in extracellular volume and hemodynamics in recurrent IH patients and controls. Methods: We performed a case-control study among prevalent hemodialysis patients with recurrent IH and hypertensive hemodialysis controls. We used bioimpedance spectroscopy and impedance cardiography to compare pre-dialysis, post-dialysis, and intradialytic change in total body water (TBW) and extracellular water (ECW), as well as cardiac index (CI) and total peripheral resistance index (TPRI). Results: The ECW/TBW was 0.453 (0.05) pre-dialysis and 0.427 (0.04) post-dialysis in controls vs. 0.478 (0.03) and 0.461 (0.03) in IH patients (p=0.01 post-dialysis). The ECW/TBW change was -0.027 (0.03) in controls and -0.013 (0.02) in IH patients (p=0.1). In controls, pre- and post-dialysis TPRI were 3254 (994) and 2469 (529) dynes/sec/cm²/m² vs. 2983 (747) and 3408 (980) dynes/sec/cm²/m² in IH patients (p=0.002 post-dialysis). There were between-group differences in TPRI change (0=0.0001), but not CI (p=0.09). Conclusions: Recurrent intradialytic hypertension is associated with higher post-dialysis extracellular volume and TPRI. Intradialytic TPRI surges account for the vasoconstrictive state post-dialysis, but intradialytic fluid shifts may contribute to post-hemodialysis volume expansion.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Extracellular Volume Overload and Increased Vasoconstriction in Patients With Recurrent Intradialytic Hypertension

Buren

Zhou

Neyra

et al. 2016

Kidney Blood Press Res

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“…One recent cohort study defined intradialytic hypertension as an increase in systolic BP ≥10 mmHg from pre to post dialysis to identify the prevalence of this phenomenon over long term follow up. Over the course of 6 months, intradialytic hypertension occurred in over 90% of the patients at least once 7 . The median percentage of treatments where intradialytic hypertension occurred during that 6 month period in this cohort was 18% such that half the subjects experienced intradialytic hypertension in 18% of the treatments or less, and half experienced intradialytic hypertension in 18% or more of their treatments.…”

Section: Epidemiologymentioning

confidence: 99%

Mechanisms and Treatment of Intradialytic Hypertension

Buren

Inrig

2016

Blood Purif

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Background: Intradialytic hypertension is a condition where there is an increase in blood pressure (BP) from pre- to post-hemodialysis; this condition has been recently identified as an independent mortality risk factor in hypertensive hemodialysis patients. The mechanisms and management of intradialytic hypertension have been explored in numerous research studies over the past few years. Summary: Patients with intradialytic hypertension have been found to be more chronically volume overloaded compared to other hemodialysis patients, although no causal role has been established. Patients with intradialytic hypertension have intradialytic vascular resistance surges that likely explain the BP increase during dialysis. Acute intradialytic changes in endothelial cell function have been proposed as etiologies for the increase in vascular resistance, although it is unclear if endothelin-1 or some other vasoconstrictive peptide is responsible. There is an association between dialysate to serum sodium gradients and BP increase during dialysis in patients with intradialytic hypertension, although it is unclear if this is related to endothelial cell activity or acute osmolar changes. In addition to probing the dry weight of patients with intradialytic hypertension, other management strategies include lowering dialysate sodium and changing antihypertensives to include carvedilol or other poorly dialyzed antihypertensives. Key Messages: Hemodialysis patients with intradialytic hypertension have an increased mortality risk compared to patients with modest decreases in BP during dialysis. Intradialytic hypertension is associated with extracellular volume overload in addition to acute increases in vascular resistance during dialysis. Management strategies should include reevaluation of dry weight and modification of both the dialysate prescription and medication prescription.

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“…[52,53] The prevalence of intradialytic hypertension ranges 5–15% among maintenance HD patients, depending on the definition. [54,55] Currently, there is no universally accepted definition of intradialytic hypertension. It is typically defined as BP increase during or immediately after HD, resulting in post-HD BP >130/80 mmHg, the KDOQI hypertension threshold.…”

Section: Intradialytic Blood Pressure Risementioning

confidence: 99%

Intradialytic Blood Pressure Abnormalities: The Highs, The Lows and All That Lies Between

Assimon

Flythe

2015

Am J Nephrol

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Background: Frequent blood pressure (BP) measurements are necessary to ensure patient safety during hemodialysis treatments. Intradialytic BPs are not optimal tools for hypertension diagnosis and cardiovascular risk stratification, but they do have critical clinical and prognostic significance. We present evidence associating intradialytic BP phenomena including fall, rise and variability with adverse clinical outcomes and review related pathophysiologic mechanisms and potential management strategies. Summary: Observational studies demonstrate associations between intradialytic hypotension, hypertension and BP variability and mortality. Lack of consensus regarding diagnostic criteria has hampered data synthesis, and prospective studies investigating optimal management strategies for BP phenomena are lacking. Mechanistic data suggest that cardiac, gut, kidney and brain ischemia may lie on the causal pathway between intradialytic hypotension and mortality, and endothelial cell dysfunction, among other factors, may be an important mediator of intradialytic hypertension and adverse outcomes. These plausible pathophysiologic links present potential therapeutic targets for future inquiry. The phenomenon of intradialytic BP variability has not been adequately studied, and practical clinical measures and treatment strategies are lacking. Key Messages: Intradialytic BP phenomena have important prognostic bearing. Clinical practice guidelines for both intradialytic hypotension and hypertension exist, but their underlying evidence is weak overall. Further research is needed to develop consensus diagnostic criteria for intradialytic hypotension, hypertension and BP variability and to elucidate optimal treatment and prevention strategies for each BP manifestation.

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The prevalence of persistent intradialytic hypertension in a hemodialysis population with extended follow-up

Abstract: Intradialytic hypertension is a persistent phenomenon in a subset of hemodialysis patients. Ultrafiltration rate was the only volume-related variable that differed between patients with and without persistent intradialytic hypertension.

Cited by 46 publications

References 13 publications

Extracellular Volume Overload and Increased Vasoconstriction in Patients With Recurrent Intradialytic Hypertension

Extracellular Volume Overload and Increased Vasoconstriction in Patients With Recurrent Intradialytic Hypertension

Mechanisms and Treatment of Intradialytic Hypertension

Intradialytic Blood Pressure Abnormalities: The Highs, The Lows and All That Lies Between

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