In an ESRD patient on regular hemodialysis presenting with a several‑week cough, intermittent palpitations, severe hypertension and anxiety attacks during dialysis, is sublingual clonidine 75 µg appropriate and what alternative pharmacologic and non‑pharmacologic management should be used?

Management of Intradialytic Hypertension, Palpitations, Cough, and Anxiety in an ESRD Patient

Do NOT Give Sublingual Clonidine 75 mcg

Clonidine is not removed by hemodialysis and its plasma concentration remains essentially unchanged during dialysis; therefore, acute sublingual dosing is ineffective for controlling intradialytic hypertension. 1 Additionally, adding any antihypertensive agent during active ultrafiltration can precipitate dangerous intradialytic hypotension in this high-risk population. 1

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Immediate Assessment During This Dialysis Session

Cardiovascular Evaluation for Palpitations

• Obtain a 12-lead ECG immediately to rule out myocardial ischemia or arrhythmias, as dialysis patients often present with atypical cardiac symptoms. 1
• Measure cardiac troponin when palpitations accompany a hypertensive episode. 1
• Do not dismiss palpitations as "only anxiety"—cardiac disease accounts for ~50% of dialysis-related deaths. 1
• Approximately 45% of dialysis patients experience anxiety, which frequently manifests as palpitations, tremor, and dyspnea. 1

Blood Pressure Context

• A blood pressure of 180/90 mmHg does NOT meet criteria for a hypertensive emergency; cardiovascular events in dialysis patients rise markedly only when systolic pressure approaches ≥180 mmHg. 1
• Both markedly high (>180 mmHg systolic) and markedly low (<110 mmHg systolic or <70 mmHg diastolic) predialysis blood pressures are associated with increased mortality. 1

Ultrafiltration Adjustment

• Temporarily reduce or pause ultrafiltration if the patient appears volume-depleted; rapid fluid removal can trigger paradoxical hypertension via sympathetic activation. 1
• Keep the ultrafiltration rate below 6 mL/h/kg to maintain hemodynamic stability. 1

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Immediate Non-Pharmacologic Interventions for Anxiety

• Implement music therapy during this dialysis session to lower anxiety levels and improve symptom perception. 2
• Cognitive-behavioral therapy or mindfulness-based interventions have demonstrated efficacy in reducing anxiety symptoms in hemodialysis patients and should be arranged for ongoing sessions. 2
• Benzodiazepines are not recommended for routine intradialytic anxiety; they should be reserved for severe, refractory cases under specialist supervision. 1

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Evaluation of the Several-Week Cough

Systematic Diagnostic Approach

• Assess for signs of fluid overload: peripheral edema, abnormal lung sounds, elevated jugular venous pressure, as pulmonary edema is a common cause of cough in ESRD patients. 3
• Review current medications for ACE inhibitors, which cause cough in approximately 5–10% of patients and are used in 55–65% of dialysis patients. 1, 3
• Evaluate for gastroesophageal reflux disease (GERD), which is a major contributor to cough in dialysis patients, with an overall cough prevalence of about 22%. 1

Cough Management Algorithm

1. If the patient is on an ACE inhibitor, discontinue it and switch to an angiotensin receptor blocker (ARB); cough typically resolves within 1–4 weeks of cessation. 1, 3
2. If fluid overload is present, intensify dialysis and implement strict sodium and fluid restriction. 3
3. If GERD is suspected, initiate high-dose proton pump inhibitor therapy and implement dietary modifications. 3
4. For severe cough affecting quality of life, consider dextromethorphan 30–60 mg for symptomatic relief; avoid codeine and other opioid antitussives due to significantly greater adverse effects in ESRD. 3

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Long-Term Blood Pressure Management Strategy

Volume Control as Primary Intervention

• Chronic volume overload is the leading cause of hypertension in hemodialysis patients; reassess and adjust the target dry weight over the next 4–12 weeks. 1
• Restrict dietary sodium to <5.8 g/day (ideally 2–3 g/day) to lessen thirst and interdialytic weight gain. 1
• Limit interdialytic weight gain to <3% of body weight between sessions. 1
• Achieve euvolemia through gradual dry-weight reduction with regular dietitian follow-up. 1

Dialysis Prescription Optimization

• Extend each dialysis session to a minimum of 4 hours and slow ultrafiltration rates to improve hemodynamic stability. 1
• Lower dialysate temperature to 34–35°C; this reduces symptomatic complications from 44% to 34%. 1
• Implement early-session sodium profiling with dialysate sodium ≈148 mEq/L to mitigate intradialytic symptoms. 1

Pharmacologic Antihypertensive Therapy (After Volume Optimization)

When predialysis blood pressure remains >140/90 mmHg after dry-weight optimization:

1. First-line: Add an ACE inhibitor or ARB (e.g., benazepril, fosinopril) to reduce left-ventricular hypertrophy and mortality. 1

   • If persistent cough develops, switch from ACE inhibitor to ARB, acknowledging residual angioedema risk. 1

2. Second-line: Add calcium-channel blockers (e.g., amlodipine). 1

3. Third-line: Add β-blockers; prefer non-dialyzable agents such as carvedilol or labetalol over highly dialyzable agents (atenolol, metoprolol) to maintain intradialytic protection against arrhythmias. 1

4. Reserve minoxidil for resistant hypertension uncontrolled on a three-drug regimen. 1

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Critical Pitfalls to Avoid

• Do not administer antihypertensive medications during active ultrafiltration without first evaluating volume status and cardiac function. 1
• Do not give indiscriminate saline boluses for blood-pressure control, as this worsens volume overload. 1
• Do not continue a twice-weekly dialysis schedule in patients with recurrent intradialytic symptoms, because it forces dangerously high ultrafiltration rates. 1
• Do not use selective serotonin reuptake inhibitors (SSRIs) routinely for anxiety in dialysis patients; existing small randomized trials have not shown consistent benefit over placebo and document increased gastrointestinal adverse effects. 2

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Monitoring and Follow-Up

• Screen regularly for depression and anxiety using validated instruments; these conditions affect roughly 25–50% of the dialysis population. 2, 1
• Reassess dry weight every 4–12 weeks with regular dietitian follow-up. 1
• Monitor predialysis blood pressure trends over 1 month to guide antihypertensive adjustments. 4
• Consider yearly echocardiography to assess left ventricular hypertrophy and function. 4