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The Management of Hypertension In Hemodialysis Patients. Dr. Abdulkareem Alsuwaida Associate Professor King Saud University. Hemodialysis Symposium 08-09 February 2014 Al Madinah AlMunawwarah.
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The Management of Hypertension In Hemodialysis Patients Dr. Abdulkareem Alsuwaida Associate Professor King Saud University Hemodialysis Symposium 08-09 February 2014 Al Madinah AlMunawwarah
Prevalence of hypertension in chronic HD pts(N=65393, mean age 61 yr, mean duration on HD 8 yr) Iseki et al. Ther Apher Dial 2007;11:183-188
Death Due to Strokes and Heart Disease Stroke Heart 32 16 16 8 8 4 stroke deaths Heart deaths 4 2 2 1 135 <120 125 135 148 168 120 125 148 168 SYSTOLIC BLOOD PRESSURE mm Hg
Unadjusted survival by baseline predialysis systolic BP Stidley et al. J Am Soc Nephrol 2006;17:513-520
“Reverse-epidemiology” • Low BP is a consequence of other disease: • Major CVD • Malnutrition-inflammation-atherosclerosis complex • LVD
Mechanism of HTN • Sodium and volume overload. • Sympathetic nervous system activity • Inappropriate renin secretion. • Alteration in endothelin and nitric oxide. • Erythropoietin therapy. • Hyperparathyroidism. • Other: • Uremic toxins, Nocturnal hypoxemia and sleep disturbances Nephrol Dial Transplant. 2004 May; 19(5):1058-68
Mechanism of HTN • Hypervolemia is the major factor • Positive Sodium balance • Increases intake and decreased excretion • Achieving DW will control 60% of cases of HTN • Assessment of DW Am J Kidney Dis. 1996 Aug; 28(2):257-61
Mechanism of HTN • Renin inappropriately high for ? etiology. • Increase vascular resistance • Increased in sympathetic activity • Originate from kidneys • Uremic metabolites that activate chemoreceptors within the kidney • Increase vascular resistance and systemic BP
When and How to measure the BP in dialysis patients? • Dialysis Unit: During, Before, or After • Home BP • ABPM
When and How to measure the BP in dialysis patients? • Predialysis SBP overestimated mean SBP by an average of 10 mm Hg • Postdialysis SBP underestimated mean SBP by an average of 7 mm Hg • BP reasings over a period of 1 to 2 weeks rather than isolated readings should be used
Home blood pressure monitoring is of greater prognostic value than hemodialysis units recordings Alborzi et al. CJASN 2007;2:1228-1234
When and How to measure the BP in dialysis patients? • Interdialytic ABP monitoring best represent BP in dialysis patients. • Only method that will show diurnal variation • Difficult to repeat, Vascular access • Home BP
Relationship between BP and mortality in dialysis patients Luther JM Kidn Int 2008;73:667-668
Target blood pressure? • Scarcity of evidence • Pre-dialysis BP < 150/90 • ABPM < 140/85 • Avoid drop of SBP greater than 30 mm Hg or post dialysis postural hypotension. • Increase mortality and hospitalization • < 110/60 mm Hg correlates significantly with the risk of death within 5 years • Kidney Int 2007;71: 454–61. • Kidney Int 2004;66:1212–20. • Am J Kidn Dis. 2005;45
ABPM systolic BP and mortality. Agarwal R Hypertension. 2010;55:762-768
Management of Hypertension • Step 1: Lifestyle modifications and control of volume status with lifestyle modifications. • Step 2: Control of volume status with dialysis. • Step 3: Administration of antihypertensive drugs.
Life style modifications • Body weight: • 'obesity paradox‘ • Mainly explained by mal-or undernutrition. • Low salt intake • 1000 to 1500 mg of sodium/day • Exercise
Life style modifications • Tobacco use • 59% more CHF • 68% more PVD • Mortality 37% • Foley et al. Kidney Int 2003; 63: 1462-7.
Management of Hypertension • Control of volume status • Limit interdialytic weight gain • a 2.5 kg is associated with a significant increase in BP • Achieve dry weight • Frequent dialysis & Longer dialysis time Agarwal R, et al. Hypertension. 2009 Mar; 53(3):500-7.
Dry Weight • Criteria to determining DW: • No marked fall in BP during dialysis. • No hypertension (predialysis BP at the beginning of the week <140/90 mm Hg). • No peripheral edema. • No pulmonary congestion on chest X-ray. • Cardiothoracic ratio ≤50% (≤53% in females).
Dry-weight reduction in hypertensive hemodialysis patients (DRIP): a randomized, controlled trial. Agarwal R, et al. Hypertension. 2009 Mar; 53(3):500-7.
Antihypertensive drugs • 160/95 mmHg immediate before the next dialysis session • Campese VM TA. Hypertension in dialysis patients. 2004. • All classes of antihypertensive can be used in dialysis patients (Except diuretics). • Compelling indications are similar
Treatment of Hypertension • ARBs and ACE are the preferable first line of antihypertensive drugs • Prevent left ventricular hypertrophy Cannella G etal.Am J Kidney Dis. 1997 Nov; 30(5):659-64. Suzuki H et al. Am J Kidney Dis. 2008 Sep; 52(3):501-6.
Pharmacokinetic properties of ACE Inhibitors in ESRD Henrich W. Principles and Practice of Dialysis
Pharmacokinetic properties of ARB’s in ESRD Henrich W. Principles and Practice of Dialysis
Pharmacologic properties of β-blockers in chronic dialysis patients Henrich W. Principles and Practice of Dialysis
Hypertension in hemodialysis patients treated with atenolol or lisinopril: a randomized controlled trial. Agarwal R et al NDT 2014 • ESRD with LVH • lisinopril (n = 100) or atenolol (n = 100) each administered three times per week after dialysis. • Results: • Hospitalizations for heart failure were worse in the lisinopril group (IRR 3.13, P = 0.021). • All-cause hospitalizations were higher in the lisinopril group [IRR 1.61 (95% CI 1.18-2.19, P = 0.002)].
Resistant Hypertension • Blood pressure remaining above goal in spite of concurrent use of 3 antihypertensive agents of different classes.
Resistant HTN in ESRD • Transdermal clonidine at weekly intervals. • Minoxidil, a potent vasodilator, • used with beta blockers • Spironolactone in Hemodialysis Patients • 25-50 mg post dialysis • Risk of hyperkalemia • Improve EF and Improve BP control • Large studies are done
Resistant Hypertension • The use of non steroidal anti-inflammatory drugs • Renovascular hypertension • Increasing cysts in polysystic kidney disease • Compliance
Resistant HTN in ESRD • Renal sympathetic nerve ablation • Hyperactivation of the sympathetic nervous system • J Clin Hypertens (Greenwich). 2012 Nov;14 • The Future? • Device-Based Therapy for Resistant Hypertension • Baroreflex Activation Therapy • Renal Denervation Therapy
Baroreflex Activation Therapy (BAT)Continuously Modulates the Autonomic Nervous System HR Vasodilation Natriuresis Renin secretion
Anatomical Location of Renal Sympathetic Nerves • Arise from T10-L1 • Follow the renal artery to the kidney • Primarily lie within the adventitia The Journal of Clinical Hypertension. 14, pages 799–801,2012 Circulation. 2002;106:1974–1979
Intradialytic hypertension • 5-15% • Mechanism • Extracellular volume overload • Increased cardiac output • Changes in sodium levels • Activation of the renin–angiotensin–aldosterone system • Overactivity of the sympathetic nervous system • Endothelial cell dysfunction. • Removal of anti HTN during dialysis
Intradialytic Hypertension • The most important treatment is adequate sodium and water removal and reducing sympathetic hyperactivity. • Changing to non-dialyzable antihypertensive medications • Altering the dialysis prescription.
Summary • Sodium excess and extracellular volume expansion is the major factor in the development of hypertension. • Lifestyle modifications is critical. • Control of volume status (Dietary salt and fluid restriction). • Correcting adequately volume expansion with dialysis. • All classes of antihypertensive drugs can be used in dialysis patients