Does End-Stage Renal Disease (ESRD) cause hypotension?

Does End-Stage Renal Disease (ESRD) Cause Hypotension?

Yes, ESRD commonly causes hypotension, particularly during hemodialysis sessions, with intradialytic hypotension occurring in 25-50% of dialysis treatments. 1

Mechanisms of Hypotension in ESRD

ESRD can lead to hypotension through several mechanisms:

1. Dialysis-related factors:

   • Rapid ultrafiltration during hemodialysis
   • Removal of fluid exceeding plasma refill rate
   • Dialysate sodium concentration imbalances
   • Core body temperature increases during dialysis 1

2. Patient-specific factors:

   • Autonomic dysfunction (common in ESRD patients)
   • Cardiac disease and impaired cardiac reserve
   • Medication effects (particularly antihypertensive medications)
   • Poor vascular compliance 1, 2

Clinical Presentation and Consequences

Hypotension in ESRD manifests in two main patterns:

1. Intradialytic hypotension (IDH):

   • Occurs during 25-50% of hemodialysis treatments
   • Symptoms include nausea, muscle cramps, dizziness, and syncope
   • Can lead to ischemic injury to vital organs 1

2. Chronic hypotension:

   • Predialysis systolic BP <110 mmHg or diastolic BP <70 mmHg
   • Associated with increased mortality risk 2

The consequences of hypotension in ESRD patients are significant:

• Increased mortality risk (71.43% higher odds of death with intradialytic events) 3
• Myocardial ischemia and stunning
• Cerebrovascular complications
• Vascular access thrombosis
• Inadequate dialysis due to shortened sessions 1, 3

Management Strategies

Prevention of Hypotension in ESRD:

1. Dialysis prescription modifications:

   • Longer, slower hemodialysis sessions
   • Short daily hemodialysis or nocturnal hemodialysis
   • Careful assessment of dry weight
   • Avoiding excessive ultrafiltration rates (keep below 6 ml/h per kg) 4, 2

2. Sodium and fluid management:

   • Consider liberalizing salt intake in patients prone to hypotension
   • Individualized dialysate sodium concentration
   • Careful fluid management between sessions 4, 5

3. Medication adjustments:

   • Adjust or temporarily suspend antihypertensive medications before dialysis
   • Prefer short-acting agents that allow for rapid adjustments 4
   • Consider timing of antihypertensive medications in relation to dialysis sessions 6

Treatment of Established Hypotension:

1. Pharmacologic interventions:

   • Midodrine (alpha-1 adrenergic agonist) 10mg orally 30 minutes before dialysis has shown effectiveness and safety over extended periods 7
   • Beta-blockers and calcium channel blockers may be protective against mortality in patients with intradialytic events 3

2. Dialysis adjustments during hypotensive episodes:

   • Reduce or pause ultrafiltration
   • Administration of isotonic saline
   • Trendelenburg positioning
   • Oxygen supplementation if needed 5, 1

Monitoring Recommendations

1. Blood pressure monitoring:

   • Monitor BP continuously during dialysis
   • Establish individualized blood pressure targets
   • Consider home BP monitoring between sessions 4, 2

2. Assessment for orthostatic hypotension:

   • Check for symptoms of orthostatic hypotension
   • Assess BP patterns both during and between dialysis sessions 4

3. Regular cardiovascular evaluation:

   • Yearly echocardiography to assess cardiac function
   • Evaluation of volume status 2

While hypertension is more commonly associated with ESRD (affecting the majority of patients), hypotension represents a significant clinical challenge that impacts morbidity and mortality. Proper management requires careful attention to dialysis prescription, medication management, and individualized care planning.