Better peridialytic blood pressure control using carvedilol in end stage renal disease patients on twice weekly maintenance hemodialysis

Epidemiology, Pathophysiology, and Clinical Perspectives of Intradialytic Hypertension

BACKGROUND

Individuals with end-stage renal disease on chronic hemodialysis (HD) may encounter numerous HD-associated complications, including intradialytic hypertension (IDHYPER). Although blood pressure (BP) follows a predictable course in the post-HD period, BP levels during the session may vary across the individuals. Typically, a decline in BP is noted during HD, but a significant proportion of patients exhibit a paradoxical elevation.

SUMMARY

Several studies have been conducted to understand the complexity of IDHYPER, but much remains to be elucidated in the future. This review article aimed to present the current evidence regarding the proposed definitions, the pathophysiologic background, the extent and clinical implications of IDHYPER, as well as the possible therapeutic options that have emerged from clinical studies.

KEY MESSAGES

IDHYPER is noted in approximately 15% of individuals undergoing HD. Several definitions have been proposed, with a systolic BP rise >10 mm Hg from pre- to post-dialysis in the hypertensive range in at least four out of six consecutive HD treatments being suggested by the latest Kidney Disease: Improving Global Outcomes. Concerning its pathophysiology, extracellular fluid overload is a crucial determinant, with endothelial dysfunction, sympathetic nervous system overdrive, renin-angiotensin-aldosterone system activation, and electrolyte alterations being important contributors. Although its association with ambulatory BP in the interdialytic period is controversial, IDHYPER is associated with adverse cardiovascular events and mortality. Moving to its management, the antihypertensive drugs of choice should ideally be nondialyzable with proven cardiovascular and mortality benefits. Finally, rigorous clinical and objective assessment of extracellular fluid volume is essential. Volume-overloaded patients should be instructed about the importance of sodium restriction, while physicians ought to alter HD settings toward a greater dry weight reduction. The use of a low-sodium dialysate and isothermic HD could also be considered on a case-by-case basis since no randomized evidence is currently available.

Management of intradialytic hypertension: current evidence and future perspectives

Intradialytic hypertension (IDH), that is, a paradoxical rise in blood pressure (BP) during or immediately after a hemodialysis session, affects approximately 10-15% of the hemodialysis population. It is currently recognized as a phenomenon of major clinical significance as recent studies have shown that BP elevation extends to the whole interdialytic interval and associates with increased cardiovascular and all-cause mortality. The pathophysiology of IDH is complex involving volume and sodium overload, endothelial dysfunction, excess renin-angiotensin-aldosterone system and sympathetic nervous system activation, and other mechanisms. For several years, there was a scarcity of studies regarding IDH treatment; recently, however, several attempts to examine the effect of nonpharmacological and pharmacological measures on BP levels in IDH are made. This review attempts to summarize this latest evidence in the field of management of IDH and discuss areas for future research.

Difference in Antihypertensive Medication Pattern in the First Year Compared to More than a Year of Maintenance Hemodialysis: A Northern India Tertiary Care Experience

Introduction There is a high prevalence of hypertension in maintenance hemodialysis patients. Information regarding prevalent pattern of antihypertensive medications will help modify it to prevent future cardiovascular morbidity and mortality.

Materials and Methods In this cross-sectional study, patients on maintenance hemodialysis, aged ≥18 years visiting Nephrology outpatient department (OPD) from April 2019 to May 2020 were included. The patients were divided into two groups based on their dialysis vintage, ≤12 months and >12 months. Their antihypertensive medication patterns and two-dimensional (2D) echocardiography (ECHO) findings were compared. Independent t-test was used to compare continuous variables. One-way analysis of variance was used to study the antihypertensive drug-dosing pattern in both the groups.

Results Out of 250 patients, 131 had a dialysis vintage of ≤12 months, whereas 119 had a vintage of >12 months. There was no significant difference in the number of antihypertensive agents used in either of the vintage groups. Calcium channel blockers (87.02 and 89.07%, respectively, in ≤12 and >12 months' vintage groups) and β blockers (64.12 and 65.54%, respectively, in ≤12 and >12 months' vintage groups) were the commonly used antihypertensive agents. Metoprolol use was higher in ≤12 months' group, whereas carvedilol usage was higher in >12 months' group (p = 0.028). Mean pill burden was more than five in both the groups. Concentric left ventricular hypertrophy was significantly more common in >12 months' group. Renin–angiotensin system (RAS) blocking agent use was limited to 3% of patients.

Conclusion This study shows a high antihypertensive pill burden in dialysis patients likely due to underlying chronic volume overload in addition to the perceived efficacy of certain class of drug in a frequent dosing pattern. Low use of RAS blocking agent was also underlined. This study highlights the need to bring about changes in the antihypertensive prescription pattern in line with the existing evidence.