How to manage hypotension in patients with End-Stage Renal Disease (ESRD)?

Management of Hypotension in ESRD Patients

Strategies to prevent and treat hypotension in ESRD patients should focus on optimizing ultrafiltration, adjusting dialysis prescriptions, and using pharmacological interventions when necessary, with careful attention to preserving residual kidney function.

Causes of Hypotension in ESRD

Hypotension in ESRD patients can occur due to several factors:

• Excessive ultrafiltration during hemodialysis
• Inadequate vascular compensation during fluid removal
• Autonomic dysfunction
• Cardiac disease
• Aggressive antihypertensive medication regimens
• Overly stringent salt restriction
• Loss of residual kidney function

Hemodialysis-Related Hypotension Management

Dialysis Prescription Modifications

1. Increase dialysis time:

   • Longer sessions allow for slower ultrafiltration rates
   • Reduces risk of intradialytic hypotension 1

2. Optimize ultrafiltration:

   • Avoid excessive ultrafiltration rates (keep below 6 ml/h per kg) 1
   • Reassess target dry weight regularly

3. Dialysate adjustments:

   • Consider increasing dialysate sodium concentration during episodes of hypotension 1
   • Reduce dialysate temperature to improve vascular stability 1

4. Consider peritoneal dialysis:

   • Patients with chronic hypotension may tolerate PD better than HD 1

Pharmacological Interventions

1. Midodrine:

   • Administer 10 mg orally 30 minutes before dialysis 2
   • Improves intradialytic blood pressure and reduces symptoms 2
   • Caution: Monitor for supine hypertension; patients should take last daily dose 3-4 hours before bedtime 3
   • Contraindications: Severe cardiac disease, urinary retention, concomitant use with other vasoconstrictors 3

2. Loop diuretics:

   • May benefit patients with residual kidney function 1
   • Reduces fluid removal requirements during dialysis 1

3. Antihypertensive medication adjustments:

   • Withhold or reduce antihypertensive medications before dialysis 1
   • Consider timing of administration (avoid pre-dialysis doses for patients prone to hypotension) 1
   • For patients requiring antihypertensives, consider medications removed by dialysis for those prone to intradialytic hypotension 4

Peritoneal Dialysis-Related Hypotension Management

1. PD prescription adjustments:

   • Reduce ultrafiltration volume by using less hypertonic glucose solutions 1
   • Consider changing icodextrin to conventional 1.5% glucose solution 1
   • Omit day dwell (in APD) or night dwell (in CAPD) in patients with significant residual kidney function 1

2. Dietary modifications:

   • Liberalize salt intake in hypotensive patients 1
   • Ensure adequate nutrition

Preserving Residual Kidney Function

Preserving residual kidney function is crucial as it:

• Helps attenuate fluctuations in fluid balance and blood pressure 1
• Permits more fluid intake, reducing dietary restrictions 1
• Contributes to continuous clearance of solutes 1

Strategies to preserve residual kidney function:

1. Avoid intradialytic hypotension 1
2. Avoid nephrotoxic medications 1
3. Consider ACE inhibitors or ARBs (with careful monitoring) 1
4. Use diuretics to maintain urine output 1

Monitoring and Follow-up

• Measure residual kidney function every 4 months using 24-hour urine collection 1
• Monitor blood pressure patterns both during and between dialysis sessions
• Assess for symptoms of orthostatic hypotension
• Evaluate cardiac function regularly, as cardiomegaly and heart failure are associated with increased mortality in patients with intradialytic hypotension 5

Special Considerations

• Beta-blockers and calcium channel blockers may be protective against mortality in patients with intradialytic events 5
• Consider dialyzability of medications when prescribing antihypertensives 4
• Intradialytic hypotension increases mortality risk by nearly 2.9 times 5, making its prevention a critical goal of therapy

Common Pitfalls to Avoid

1. Overly aggressive ultrafiltration leading to rapid volume depletion
2. Failure to adjust antihypertensive medications before dialysis
3. Ignoring residual kidney function preservation
4. Not considering cardiac status when managing hypotension
5. Using midodrine without monitoring for supine hypertension

By systematically addressing these factors, hypotension in ESRD patients can be effectively managed while preserving residual kidney function and improving overall outcomes.