It is a presentation on How to Manage Hypotension During Haemodialysis Sessions

2.  Nephrology Dialysis, Transplant (2007) 22
[Suppl 2]:

3.  Incidence
 Definition
 Significance
 Patho-physiology
 Prevention
 Treatment

4.  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

5.  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
nursing
interventions.

6.  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

7.  Age,
 female Gender,
 Presence of diabetes mellitus,
 Hyperphosphataemia,
 Presence of coronary artery disease,
 Renal diagnosis other than
glomerulonephritis
 use of nitrates

8.  Interplay of 04 factors
1. Ultra-filtration
2. Refill blood volume
3. Dialysate –Na+,Ca++,Temp
4. Patient sensitivity to volume withdrawn

9.  Autonomic neuropathy, which can
be 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.

10.  Hydration of Patient
 Dry Weight
 Radiological Inv., CT Ratio, IVC diameter
 Multi frequency Bio-impedance
 BNP level ,Cyclic GMP

11.  Checking of Heart rate
 Blood pressure
 Patient alarm

12.  Cardiac Evaluation
 Diastolic dysfunction
 Ejection Fraction
 Ischemia assessment
 Pericardium assessment

13.  Dietary Salt
 Food intake –Pre Dialysis
 During Dialysis …..???
 Caffiene …No Benefit

14.  Pulsed Ultrafiltration…increases IDH.
 IntraDialytic Blood Volume monitoring
 Perfusion state ,Oxygenation and anti-
coagulation Milieu

15.  Na+>> or equal 144mEq less chances
 Bicarbonate
 Ca++ low dialysate
 Mg++ low <.25 mMoL

16.  Bio-Compatibility
 Reuse of incompletely treated
 Inadequately washed

17.  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)

18.  Ultrafiltration Followed by Isovolumic
Dialysis ……Not Rcommended

19.  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

20.  Avoidance of antihypertensive drugs
and prescription of vasoactive
medication
 Antihypertensives ..Ca Channel blockers
 Nitrates …independent factor.

21.  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, headach
e, neck pain and weakness.

22.  Lysine vasopressine,
 Ergotamine,
 Methylene blue
 Dobutamine
 Insufficient data to make
recommendation

23.  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

24.  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.

25.  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)

26.  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

27.  Consider midodrine.
 Consider L-carnitine supplementation.
 Consider peritoneal dialysis.

28.  Trendelenburg position
 Stopping ultrafiltration
 Infusion fluids

29.  Blood Best
 Colloid Next
 Not available ..Crystalliod…
 Crystalliod –Dextrose 25%<10%
 Saline 3%< NS

30.  Peritoneal Dialysis
 Artificial Kidney

31.  Shri B N Bordoloi…….Art of Dialysis
 Faculty….Science of Nephrology
 Dr P J Mahanta ,DM(Nephro) Assistant
Prof for entrusting me this seminar

32. Thank You Madam &
Sir