Is a high glucose concentration dialysate bag (indicated by a red color) suitable for patients with hypertension (high blood pressure)?

Red Dialysate Bags Are Not Recommended for Patients with Hypertension

High glucose concentration dialysate bags (red bags) should be avoided in patients with hypertension as they can worsen blood pressure control and lead to adverse hemodynamic effects.

Understanding the Impact of Dialysate Solutions on Blood Pressure

Glucose-Based Dialysate and Blood Pressure

• High glucose concentration dialysate (indicated by red color) is associated with significantly higher blood pressure compared to lower glucose concentrations or icodextrin solutions 1
• The higher blood pressure with hypertonic glucose solutions occurs despite achieving greater ultrafiltration volume and sodium removal 1
• The mechanism involves increased heart rate, stroke volume, and cardiac output during high glucose concentration dwells 1

Sodium and Volume Considerations

• The majority of hypertensive hemodialysis patients develop hypertension due to fluid overload secondary to sodium and water retention 2
• High dialysate sodium concentrations can lead to inadequate sodium removal during dialysis, resulting in higher interdialytic weight gains and worsening hypertension 2
• Centers predominantly using higher dialysate sodium concentrations (140 mmol/L) report increased interdialytic weight gains and more difficult blood pressure control 3

Recommended Alternatives for Hypertensive Patients

Icodextrin for Long Dwells

• Icodextrin solution is recommended for long dwells to increase ultrafiltration and decrease extracellular fluid volume in hypertensive patients 4
• Icodextrin demonstrates better hemodynamic profiles compared to high glucose concentration solutions 1

Optimizing Dialysate Sodium

• Lower dialysate sodium concentrations (135-140 mmol/L) are recommended to reduce thirst, fluid gain, and hypertension 2, 5
• A randomized crossover study showed that lower dialysate sodium concentrations significantly decreased systolic blood pressure and ameliorated intradialytic hypertension 5
• Avoiding sodium profiling techniques is advised as they can aggravate thirst, fluid gain, and hypertension 2

Additional Management Strategies for Hypertension

Dietary Modifications

• Restrict sodium intake to approximately 2g per day (equivalent to about 5g of salt) 2
• Adopt a healthy and balanced diet such as Mediterranean or DASH diets to help reduce blood pressure 2
• Restrict free sugar consumption, particularly sugar-sweetened beverages, to a maximum of 10% of energy intake 2

Volume Management

• Implement appropriate ultrafiltration with every dialysis treatment to achieve and maintain true dry weight 2
• Be aware of the "lag phenomenon" where blood pressure continues to decrease for up to 8 months after achieving normal extracellular fluid volume 2
• Consider using loop diuretics cautiously in patients with residual kidney function to promote sodium and water loss 2

Monitoring and Assessment

• Assess blood pressure and volume status monthly 4
• Evaluate drain volume, residual kidney function, and dietary salt/water intake regularly 4
• Monitor for symptoms of fluid overload such as basilar airspace opacification which can indicate pulmonary edema 6

Common Pitfalls and Cautions

• Avoid overly aggressive ultrafiltration as it can lead to intradialytic hypotension 6
• Be aware that high glucose dialysate can contribute significant calories (>500g of dextrose over 24 hours), potentially leading to metabolic complications 7
• The relationship between extracellular volume and blood pressure may be sigmoidal rather than linear in some patients, requiring careful monitoring 2