Intradialytic Hypertension

Etiology

  • Genetic predisposition
  • Pre existing hypertension
  • Extracellular volume excess
  • Increased renin- angiotensin system activity (possibly in the presence of increased   sodium overload)
  • Increased sympathetic activity
  • Increased endothelin-1 to nitric oxide ratio
  • Uremic toxins (ADMA)
  • Blood hyperviscosity
  • Correction of hypoxia- induced vasoconstriction
  • Increased dialysate sodium
  • Secondary hyperparathyroidism

Treatment  and Prevention

  • Lifestyle modifications such as weight reduction, dietary modification, sodium restriction, physical activity and moderation of alcohol consumption can reduce systolic blood pressure from 2-14 mm Hg1
  • Adjustment of target weight on a regular basis. Gradual reduction of interdialytic weight gain over a few weeks using zero sodium balance, salt restriction, longer dialysis or extra dialysis sessions may yield a significant benefit2
  • Reducing erythropoeitin dose in patients with severe hypertension and withholding of anti-hypertensive medications on the day of dialysis
  • Nephrectomy in resistant cases
  • Renal transplantation or conversion to PD

References:

  1. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 289:2560-2572, 2003.
  2. Charra B. ‘Dry weight’ in dialysis: the history of a concept. Nephrol Dial Transplant. 13:1882-1885, 1998