How to manage hypotension in end-stage renal disease (ESRD) patients?

Management of Hypotension in End-Stage Renal Disease Patients

The most effective approach to managing hypotension in ESRD patients involves addressing volume status, optimizing dialysis prescription, and using targeted pharmacological interventions, with midodrine being the first-line medication for persistent intradialytic hypotension. 1

Initial Assessment and Volume Management

• Evaluate the accuracy of the patient's prescribed target weight, as hypotension may indicate that it is set too low 2, 1
• Assess for fluid retention and adjust diuretic regimen if the patient still has residual kidney function 2
• Consider extending dialysis treatment time to reduce ultrafiltration rate when possible, as higher ultrafiltration rates (even as low as 6 ml/h per kg) are associated with higher mortality risk 2
• Limit interdialytic weight gain by restricting dietary sodium to <2.0 g/d to minimize the need for aggressive fluid removal during dialysis 2, 1

Dialysis Prescription Modifications

• Implement sodium profiling (starting with higher sodium concentration and gradually decreasing it) to maintain vascular stability during dialysis 1
• Reduce dialysate temperature from 37°C to 34-35°C to increase peripheral vasoconstriction and cardiac output 1, 3
• Switch from acetate-containing dialysate to bicarbonate-containing dialysate to prevent inappropriate decreases in total vascular resistance 1
• Avoid food intake immediately before or during hemodialysis as this can cause decreased peripheral vascular resistance 1

Pharmacological Management

• Administer midodrine (an oral selective α1-adrenergic agonist) 10 mg approximately 30 minutes before dialysis sessions to prevent intradialytic hypotension 4, 5
• Consider increasing midodrine dosing to 10 mg three times daily if hypotension persists between dialysis sessions 4, 5
• For severe hypotension during dialysis, temporarily stop ultrafiltration and administer intravenous normal saline bolus to rapidly expand plasma volume 1
• Consider dopamine infusion for refractory hypotension at doses of 2-5 mcg/kg/min, which can improve renal perfusion and cardiac output 6

Antihypertensive Medication Management

• Review and adjust antihypertensive medications, particularly those taken before dialysis 2, 1
• Consider temporarily holding or reducing doses of beta-blockers if they contribute to intradialytic hypotension 4
• When beta-blockers are necessary (e.g., for atrial fibrillation), select non-dialyzable agents (e.g., carvedilol, propranolol) over highly dialyzable ones (e.g., atenolol, metoprolol) to maintain cardiovascular protection during dialysis 2
• For patients with chronic hypotension, consider discontinuing ACE inhibitors or ARBs as they may worsen hypotension in ESRD patients 2

Monitoring and Prevention

• Monitor blood pressure and heart rate before, during, and after dialysis sessions 4
• Place patients in Trendelenburg position (head down, legs elevated) during episodes of acute hypotension to improve venous return 1
• Administer supplemental oxygen during hypotensive episodes to improve tissue oxygenation 1
• Consider raising hemoglobin to 11 g/L to improve oxygen-carrying capacity and prevent hypotension 1

Special Considerations

• Avoid episodes of intravascular volume depletion during hemodialysis as they can contribute to more rapid loss of residual kidney function 2
• For patients with persistent hypotension despite interventions, consider peritoneal dialysis as an alternative modality 2
• Be aware that intradialytic hypotension is associated with increased mortality risk (increasing probability of death by 2.9 times) and requires aggressive management 7
• For patients with cardiac disease, assess cardiovascular status if hypotensive episodes occur frequently, as coronary flow reserve may be compromised in patients with left ventricular hypertrophy 8

Common Pitfalls to Avoid

• Do not abruptly discontinue beta-blockers in patients with cardiovascular disease, as this may precipitate rebound tachycardia or ischemia 4
• Avoid simultaneous administration of multiple antihypertensive medications before dialysis 4
• Be cautious with increased dialysate sodium as it may lead to increased thirst, interdialytic weight gain, and hypertension between dialysis sessions 1
• Remember that reduced dialysate temperature may cause uncomfortable hypothermia in some patients 1
• Do not use ACE inhibitors in patients treated with polyacrylonitrile dialysis membranes due to risk of anaphylactoid dialyzer reactions 2