Hypertension in Hemodialysis Patients Ouppatham Supasyndhh, M.D. Division of Nephrology Phramogkutklao Hospital
Topics 1. Prevalence of hypertension in hemodialysis (HD) patient 2. Methods using to determine blood pressure 3. Diagnosis of hypertension 4. Pathophysiology 5. Management
Topics 1. Prevalence of hypertension in hemodialysis (HD) patient 2. Methods using to determine blood pressure 3. Diagnosis of hypertension 4. Pathophysiology 5. Management
Pre-dialysis BP Mean SBP 153.1 + 21.2 mmHg DBP 79.2 + 12.3 mmHg Post-dialysis BP Mean SBP 138.0 + 19.2 mmHg DBP 71.5 + 11.1 mmHg Li Z. Am J Kid Dis,2006;48(4):606-615
N = 56,338 N = 65,950 Li Z. Am J Kid Dis,2006;48(4):606-615
Li Z. Am J Kid Dis,2006;48(4):606-615
Epidemiology (70-80%) Authors N Method Definition Prevalence 489 Peridialytic BP 87.7 Rahman M 1238 Peridialytic BP >140/90 74 (1999) 2535 85.8 Pre-HD >140/90 at 74.2 Hemo study base line 82 (1990) >150/85 Agarwal R (2003) 65,950 Peridialytic BP SBP > 140 Li Z. 369 ABPM >135/85 (2006) Agarwal R (2011)
Topics 1. Prevalence of hypertension in hemodialysis (HD) patient 2. Methods using to determine blood pressure 3. Diagnosis of hypertension 4. Pathophysiology 5. Management
Q1: Which methods is the most associated with gold standard BP measurement method using for dialysis patient? A. Peridialytic BP measurement B. Ambulatory BP monitoring C. Home BP monotoring D. Intradialytic BP measurement
Methods Method Description Comments Peridialytic BP Measures both before Easily available but highly variable and after HD No attention to standardize the technique of measurement Intradilaytic BP Median of all BP Factors affected on BP: measures during one HD • white coat effect • limited time for ralaxation BP blood pressure; HD Hemodialysis • anxiety, previous bilateral upper limbs attemps of AV fistula • validity of devices Easily avaliable
Methods Method Description Comments Ambulatory BP Measured every 20-30 Gold standard (but cumbersome) min over 44 h • Strongly correlates with LVH • Detects non-dipping nocturnal BP • Predicts all cause mortality and cardiovascular outcomes Treatment burden (sleep disturbance) Home BP Measured twice daily at Correlates well to ABP and accessible home by most patients BP blood pressure; HD Hemodialysis; LVH Left ventricular hypertrophy
18 studies, N =692 Pre-dialysis systolic BP generally overestimated ABP. In contrast post-dialysis BP underestimated average ABP Agarwal R., Clin J Am Soc Nephrol 2006; 1: 389-398
N = 150, Follow up 24 months Alborzi P, Clin J Am Soc Nephrol 2007; 2: 1228–1234
Dialysis unit BP N = 403/1705 • both low and high ends of the SBP distribution were associated with higher rates of mortality Out of dialysis unit BP N = 326/403 • higher SBP increases risk of mortality Bansal N. the CRIC study. Hypertension.2015;65(1): 93–100
Pre-dialysis SBP DOPPs N =24,525 Higher mortality risk was observed; • Pre-dialysis SBP < 130 or > 160 mmHg • Pre-dialysis DBP < 60 mmHg Pre-dialysis DBP Robinson BM. Kidney Int. 2012; 82(5): 570–580
Advantage of Home BP 1. Predicts gold standard ABPM 2. Reproducibility 3. Reflects changes in dry weight 4. Correlates to left ventricular hypertrophy 5. Predicts cardiovascular events 6. Predicts mortality 7. RCT evidence for efficacy of BP control 8. Recommended by major professional societies
Q1: Which methods is the most associated with gold standard BP measurement method using for dialysis patient? A. Peridialytic BP measurement B. Ambulatory BP monitoring C. Home BP monotoring D. Intradialytic BP measurement
Topics 1. Prevalence of hypertension in hemodialysis (HD) patient 2. Methods using to determine blood pressure 3. Diagnosis of hypertension 4. Pathophysiology 5. Management
Q2: Which of the followings is the definition of hypertension in dialysis patient? A. Home BP ≥ 135/85 mmHg B. Pre-dialysis BP > 150/90 mmHg C. ABPM ≥ 135/85 mmHg D. Post-dialysis BP > 140/90 mmHg
Diagnosis 2004 2017 2021
Diagnosis • Pre-dialysis BP > 140/90 mm Hg 2004 or • Post-dialysis BP > 130/80 mm Hg,
Diagnosis (based on home BP) Home BP in HD: average BP ≥ 135/85 mmHg 1. collected in the morning and in the evening 2. over 6 non-dialysis days (covering a period of 2 weeks) 3. should be performed in a quiet room, seated position, back and arm supported 4. after 5 min of rest and with two measurements per occasion taken 1–2 min apart Sarafidis PA. Nephrol Dial Transplant.2017;32:620-640
Diagnosis (based on ABPM) ABPM in HD: average BP ≥ 130/80 mmHg 1. over 24-h monitoring during a mid-week day free of HD 2. whenever feasible, ABPM should be extended to 44h, that is, covering a whole mid-week dialysis interval Sarafidis PA. Nephrol Dial Transplant.2017;32:620-640
Diagnosis (based on home BP or ABPM) Home BP in PD: average BP ≥ 135/85 mmHg 1. collected in the morning and in the evening 2. over 7 non-dialysis days (measurement collected as home BP in HD) ABPM in PD: average BP ≥ 130/80 mmHg over 24 hours Sarafidis PA. Nephrol Dial Transplant.2017;32:620-640
Diagnosis For HD patients, if ABPM or home BP measurements are not available 1. Office BP ≥ 140/90 mmHg recommended by current guidelines for the definition of hypertension in CKD patients 2. Taken in a mid-week day free of HD (the average of 3 measurements with 1–2 min intervals) 3. Obtained in the sitting position by trained personnel after at least 5 min of quiet rest Sarafidis PA. Nephrol Dial Transplant.2017;32:620-640
Diagnosis For PD patients, if ABPM or home BP measurements are not available 1. Office BP ≥ 140/90 mmHg 2. Measurement collected as office BP in HD Sarafidis PA. Nephrol Dial Transplant.2017;32:620-640
Intradialytic Hypertension Features • 5-15% prevalence • No single accepted definiton • Associated with increased mortality • Associated with volume overload and endothelial dysfunction • Evidence for improvement with dry weight reduction and carvidilol therapy
Intradialytic Hypertension Definition • ≥ 15 mmHg increase of mean arterial pressure (MAP) between start and the end of HD • ≥ 10 mmHg increase of SBP during dialysis Inrig JK, et al. Kidney Int 2007;71: 454-461
Inrig JK, et al. Kidney Int 2007;71: 454-461
Q2: Which of the followings is the definition of hypertension in dialysis patient? A. Home BP ≥ 135/85 mmHg B. Pre-dialysis BP > 150/90 mmHg C. ABPM ≥ 135/85 mmHg D. Post-dialysis BP > 140/90 mmHg
Topics 1. Prevalence of hypertension in hemodialysis (HD) patient 2. Methods using to determine blood pressure 3. Diagnosis of hypertension 4. Pathophysiology 5. Management
Q3: Which one is the pathophysiology of hypertension in dialysis patient? A. Obesity B. Use of erythropoietin C. Dialyzable antihypertensive drugs D. Severe stress
Pathophysiology Main pathogenic mechanisms 1. Sodium and volume overload 2. Increased arterial stiffness 3. Sympathetic overactivity 4. Renin-angiotensin-aldosterone system activation 5. Endothelial dysfunction 6. Sleep apnea 7. Use of erythropoietin Sarafidis PA. Nephrol Dial Transplant.2017;32:620-640
Volume overload • Osmotically inactive sodium retention in skin and connective tissue • Triggers macrophage • VEGF (vascular endothelial growth factor) release • Endothelial dysfunction • Increase BP Sarafidis PA. Nephrol Dial Transplant.2017;32:620-640
Clinical sign 1. Elevated interdialytic BP by home BP or ABPM 2. Multiple antihypertensive medications 3. Low interdialytic weight gain 4. Symptoms and signs: peripheral edema, cardiomegaly, elevated JVP, pulmonary congestion, pleural effusion
Erythropoietin • increased circulating endothelin-1 • increased sensitivity to the pressor effect of angiotensin II • increased blood viscosity and increased vascular sensitivity to noradrenergic stimuli • Higher erythropoietin doses • higher target hemoglobin levels • route of administration (intravenous versus subcutaneous) Sarafidis PA. Nephrol Dial Transplant.2017;32:620-640
Q3: Which one is the pathophysiology of hypertension in dialysis patient? A. Obesity B. Use of erythropoietin C. Dialyzable antihypertensive drugs D. Severe stress
Topics 1. Prevalence of hypertension in hemodialysis (HD) patient 2. Methods using to determine blood pressure 3. Diagnosis of hypertension 4. Pathophysiology 5. Management
Volume overload 1. Weight reduction 2. Salt restriction Weight reduction • progressive decline in post dialysis body weight over a 4- 8-week period after initiation of maintenance hemodialysis Dry weight definition* • the post dialysis body weight at which ECV in within the normal range or the target BP value without the need for • antihypertensive medication *Levin NW. Kidney Int 2010;77:273-84.
Treatment group = 87 Control group = 45 Weight reduction protocol: Agarwal R. Hypertension. 2009;53(3):500-507 - 0.1 kg/10 kgBW every HD - If hypotension developed, decrease UF 50%
Sodium Control • Restriction of sodium intake 1.5 g Na or 4 g NaCl/day • Decreasing dialysate Na towards pre-dialysis sodium • Avoidace sodium containing drug Sarafidis PA. Nephrol Dial Transplant.2017;32:620-640
Low dialysate sodium concentrations significantly decreased systolic BP and ameliorated intradialytic hypertension High dialysate Na = serum Na + 5 mEq/L Low dialysate Na = serum Na - 5 mEq/L (lower limit = 134 mEq/L) Standard DNa 139-140 mEq/L Inrig JK, et al. Am J Kidney Dis. 2015;65(3):464-473
Barriers towards achievement of dry weight 1. Difficulty in assessing dry weight 2. Fear of patient symptoms ( intradilytic hypotension, muscle cramp, nausea and vomitiing 3. Risk of complications ((cardiovascular event, AV access loss) Sarafidis PA. Nephrol Dial Transplant.2017;32:620-640
Barriers towards achievement of dry weight 4. Physician and nurse inertia (ease of prescribing a new drug vs. dry weight adjustment) 5. Lack of patient education on dietary sodium and fluid restriction 6. Low compliance with sodium diet and high interdialytic weight gain Sarafidis PA. Nephrol Dial Transplant.2017;32:620-640
Barriers towards achievement of dry weight 7. Use of sodium contain medication eg. sodium bicarbonate 8. Inappropriate dialysate sodium 9. Use of high UF rates 10. Short dialysis session Sarafidis PA. Nephrol Dial Transplant.2017;32:620-640
Barriers towards achievement of dry weight 10. Concomittent disease (heart failure, autonomin dsfunctionX 11. Use of high number antihypertensive agents 12. Use of “fast and easy” to treatm intradialytic hypotension (cessation of UF, hypertonic sodium infusion, increase dialysate sodium concentration, premature termination of HDgain Sarafidis PA. Nephrol Dial Transplant.2017;32:620-640
Q4: A MHD male patient experience intradialytic HT PE: Home BP 160/80 vs. Pre-HD BP 180/80 mmHg. He usually stops taking morning medication in the day of dialysis PE: JVP 3 cm. No edema Lab. Na 135, K 3.5, Ca 8.5, Hb 10 g/L Dialysate Na 138, K2, Ca 2.5 ESA 15,000 u/wk, Amlopine 10 mg pc, Metoprolol 25 mg pc morning
Q4 How do you manage hypertension in this patient? 1. Taking medications in the evening 2. Reduce dry weight 3. Reduce dose of erythropoietin 4. Increase metoprolol twice daily
Pharmacokinetics Class Half-life Range of dosing % removal by HD Captopril 20-30 h 12.5-50 mg q 24 h Yes Enalapril Prolonged 2.5-10 mg q 24 h 35% Ramipril Prolonged 2.5-10 mg q 24 h Losartan 50-100 mg q 24 h < 30% Candesartan 4h None Telmisartan 5-9 h 4-32 mg q 24 h None Valsartan 24 h 40-80 mg q 24 h None Irbesartan 6h 80-160 mg q 24 h None 11-15 h 75-300 mg q 24 h None Inrig JK, et al. Semin Dial. 2010;23(3):290-297
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