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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withdrawn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