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Rogan A, McGregor G, Weston C, Krishnan N, Higgins R, Zehnder D, Ting SMS. Exaggerated blood pressure response to dynamic exercise despite chronic refractory hypotension: results of a human case study. BMC Nephrol 2015; 16:81. [PMID: 26055191 PMCID: PMC4460705 DOI: 10.1186/s12882-015-0076-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 05/21/2015] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Chronic refractory hypotension is a rare but significant mortality risk in renal failure patients. Such aberrant physiology usually deems patient unfit for renal transplant surgery. Exercise stimulates the mechano-chemoreceptors in the skeletal muscle thereby modulating the sympathetic effects on blood pressure regulation. The haemodynamic response to dynamic exercise in such patients has not been previously investigated. We present a case with severe chronic hypotension who underwent exercise testing before and after renal transplantation, with marked differences in blood pressure response to exercise. CASE PRESENTATION A 40-year old haemodialysis-dependent patient with a 2 year history of refractory hypotension (≤80/50 mmHg) was referred for living donor renal transplantation at our tertiary centre. Each dialysis session was often less than 2 h and 30 min due to symptomatic hypotension. As part of the cardiovascular assessment, she underwent haemodynamic evaluation with cardiopulmonary exercise testing. Blood pressure normalized during unloaded pedalling but was exaggerated at maximal workload whereby it rose from 82/50 mmHg to a peak of 201/120 mmHg. Transthoracic echocardiography, tonometric measure of central vascular compliance and myocardial perfusion scan were normal. She subsequently underwent an antibody-incompatible renal transplantation and was vasopressor reliant for 14 days during the post-operative period. Eight weeks following transplant, resting blood pressure was normal and a physiological exercise-haemodynamic response was observed during a repeat cardiopulmonary exercise testing. CONCLUSION This case highlights the potential therapeutic role of unloaded leg cycling exercise during dialysis session to correct chronic hypotension, allowing patients to have greater tolerance to fluid shift. It also adds to existing evidence that sympathetic dysfunction is reversible with renal transplant. Furthermore chronic hypotension with preserved exercise-haemodynamic response and cardiovascular reserve should not preclude these patients from renal transplant surgery.
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Affiliation(s)
- Alice Rogan
- Departments of Renal Medicine and Transplantation, University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK.
| | - Gordon McGregor
- Departments of Renal Medicine and Transplantation, University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK. .,Departments of Cardiac Exercise Physiology, University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK.
| | - Charles Weston
- Department of Nephrology, Dorset County Hospital NHS Foundation Trust, Dorchester, UK.
| | - Nithya Krishnan
- Departments of Renal Medicine and Transplantation, University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK.
| | - Robert Higgins
- Departments of Renal Medicine and Transplantation, University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK.
| | - Daniel Zehnder
- Departments of Renal Medicine and Transplantation, University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK. .,Division of Metabolic and Vascular Health, The University of Warwick, Coventry, UK.
| | - Stephen M S Ting
- Departments of Renal Medicine and Transplantation, University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK. .,Division of Metabolic and Vascular Health, The University of Warwick, Coventry, UK.
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Fellstrom B, Holdaas H, Jardine A. Functional cardiopulmonary exercise testing in potential renal transplant recipients. J Am Soc Nephrol 2013; 25:8-9. [PMID: 24231661 DOI: 10.1681/asn.2013090996] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Bengt Fellstrom
- Division of Renal Medicine, Department of Medical Sciences, University of Uppsala, Uppsala, Sweden
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