How to manage a patient with neurogenic orthostatic hypotension, supine hypertension, and End-Stage Renal Disease (ESRD)?

Management of Neurogenic Orthostatic Hypotension with Supine Hypertension in ESRD

For patients with neurogenic orthostatic hypotension, supine hypertension, and ESRD, non-pharmacological approaches should be the first-line treatment, with careful selection of pharmacological agents that minimize worsening of supine hypertension and consider renal clearance limitations. 1

Non-Pharmacological Management (First-Line)

Immediate Interventions

• Physical counter-pressure maneuvers - Leg crossing, squatting, and muscle tensing to increase peripheral resistance 1
• Compression garments - Abdominal binders and lower extremity compression stockings (30-40 mmHg) 1
• Head elevation during sleep - Sleep with head of bed elevated 30° to minimize supine hypertension 1, 2
• Small, frequent meals - To reduce postprandial hypotension 1

Fluid and Salt Management (Modified for ESRD)

• Fluid management must be carefully balanced with ESRD fluid restrictions
• Salt intake should be individualized based on dialysis schedule and residual renal function 3
• Acute water ingestion (if not fluid restricted) - 16 oz of water can temporarily increase blood pressure through osmotic effects 1

Pharmacological Management

First-Line Options for ESRD Patients

• Midodrine (2.5-10 mg, 2-3 times daily)
  • Start with lower dose (2.5 mg) due to renal impairment 4
  • Last dose at least 4 hours before bedtime to minimize supine hypertension 1, 4
  • Monitor for supine hypertension, urinary retention 4

Second-Line Options (Use with Caution)

• Droxidopa (100-600 mg three times daily)
  • FDA-approved for neurogenic orthostatic hypotension 1
  • May be more beneficial in patients with peripheral sympathetic denervation 5
  • Last dose at least 4 hours before bedtime 1

Avoid or Use with Extreme Caution

• Fludrocortisone - Generally avoided in ESRD due to risk of fluid retention, electrolyte abnormalities, and worsening supine hypertension 3, 5
• Pyridostigmine - May be considered in patients with preserved "sympathetic reserve" but limited data in ESRD 6

Management of Supine Hypertension

• Avoid supine position - Elevate head of bed 30° during sleep 1, 2
• Time medication administration - Last dose of pressor agents at least 4 hours before bedtime 1, 4
• Short-acting antihypertensives at bedtime may be considered but use with extreme caution in ESRD 2
• Monitor supine blood pressure regularly, especially after starting pressor medications 4

Special Considerations for ESRD

• Medication dosing - Start with lower doses of all medications due to impaired renal clearance 4
• Dialysis timing - Coordinate medication administration with dialysis schedule to prevent excessive hypotension during or after dialysis
• Volume status - Carefully assess and manage volume status in relation to dialysis schedule
• Electrolyte monitoring - More frequent monitoring of electrolytes, especially if using any medications that may affect electrolyte balance

Treatment Algorithm

1. Start with non-pharmacological measures

   • Compression garments, physical counter-maneuvers, head elevation during sleep

2. If symptoms persist, add pharmacological therapy

   • Begin with low-dose midodrine (2.5 mg) with careful titration
   • Administer last dose at least 4 hours before bedtime

3. If inadequate response to midodrine:

   • Consider adding droxidopa (starting at 100 mg TID)
   • Monitor closely for worsening supine hypertension

4. Regular monitoring:

   • Measure both standing and supine blood pressure
   • Assess for symptoms of orthostatic hypotension and supine hypertension
   • Monitor renal function and electrolytes

Common Pitfalls and Caveats

• Overtreatment of orthostatic hypotension can worsen supine hypertension
• Undertreatment increases fall risk and decreases quality of life
• Medication timing is critical - avoid pressor medications close to bedtime
• Fluid management must balance orthostatic hypotension treatment with ESRD fluid restrictions
• Polypharmacy can worsen both conditions - review and discontinue medications that may exacerbate orthostatic hypotension (e.g., opioids, anticholinergics, tricyclic antidepressants) 3, 1

The primary therapeutic goal is to minimize postural symptoms rather than to restore normotension 1, with careful attention to preventing worsening of supine hypertension, which can lead to target organ damage and worsen orthostatic hypotension through pressure natriuresis 2.