Comparison of Dialysis and Clinical Characteristics of Patients with Frequent and Occasional Hemodialysis-Associated Hypotension

Abstract

Background: Symptomatic dialysis hypotension (DH) continues to be a common problem. By comparing patients prone and resistant to DH, several dialysis session and patient related characteristics have been identified that confer susceptibility to DH. Less is known, however, about the comparison of patients with frequent and only occasional DH. The aim of the study was to compare clinical and dialysis-session- (complicated by hypotension) related data between those with frequent (fDH) and those with occasional dialysis hypotension (oDH). Methods: Nine hundred and fifty-eight patients at 11 dialysis units were followed for 10 months and characteristics of patients with fDH (≧10 hypotensive events necessitating medical intervention) (n = 96) were compared to that of patients with oDH (1 or 2 events/10 months) (n = 130). Significant and independent predictors of fDH were obtained by multivariate logistic regression. Results: Significant differences between fDH vs. oDH patients were older age (64.4 vs. 56.9 years, p < 0.001), more females (66 vs. 46%, p < 0.005) in fDH. More fDH patients had diabetes (27 vs. 15%, p < 0.05) and less had glomerulonephritis (15 vs. 35%, p < 0.001) as the cause for ESRD. Coronary artery disease (68 vs. 50%, p < 0.01) and long-acting nitrate treatment (51 vs. 30%, p < 0.001) was more frequent while treatment with ACEI (33 vs. 48%, p < 0.05) or Ca-channel blockers (40 vs. 53%, p < 0.05) were less frequent in patients with fDH. Patients with fDH had higher serum phosphorus levels (1.99 vs. 1.79 mmol, p < 0.005). Dialysis session related data were similar but the hypotensive episode occurred earlier during dialysis in fDH (136 vs. 156 min, p < 0.01). In multivariate analysis, significant independent predictors of fDH were older age (OR = 1.04 [1.02–1.07]), lack of glomerulonephritis as renal diagnosis (2.63 [1.18–5.87]), high phosphorus levels (5.0 [2.45–10.0]), lack of use of Ca-channel blockers (2.09 [1.12–3.91]), and the use of nitrates (2.38 [1.24–4.55]). Conclusion: Features of the dialysis sessions complicated by DH seem to be similar between patients with fDH and oDH, while patient characteristics such as older age, renal diagnosis other than glomerulonephritis, higher serum phosphorus levels, use of nitrates, and lack of use of calcium channel blockers are significantly and independently associated with fDH.

Intradialytic Hypotension and Vascular Access Thrombosis

“…Current clinical practice already dictates avoidance of intradialytic hypotension, and our results add another item to the growing list of adverse clinical outcomes associated with intradialytic hypotension, such as decreased quality of life, inadequate dialysis, myocardial dysfunction, and death. 16,[33][34][35] We also demonstrate that lower pre-and postdialysis SBP are associated with higher relative rates of fistula and graft thrombosis. Uncertainty regarding appropriate BP targets in hemodialysis continues, and whether higher BP targets are warranted in particular situations remains to be proven.…”

The Very Old on Hemodialysis: 8 Years' Experience in a Single Unit

“…Elderly patients are often prescribed shorter HDx treatment time as they weigh less, often have a lower interdialytic weight gain and their ultrafiltration requirements are lower. Despite this, dialysis-induced hypotension is more frequent in the elderly [18], and these events may compromise cerebral perfusion and cognitive function and cause episodes of nonocclusive mesenteric ischemia and ischemic optic neuropathy [19,20,21]. Just recently, Flythe et al [17] substantiated our findings by showing increased patient mortality (hazard ratio 1.34) in patients >65 years old when dialyzed for a shorter dialysis session length.…”

Optimising Treatment of End-Stage Renal Disease in the Elderly

“…In a recent report from the Dialysis Outcomes and Practice Patterns Study (DOPPS), 46-55% of patients aged ≥75 years had coronary artery disease, 25-30% cerebrovascular disease, and up to 50% had congestive cardiac failure and peripheral vascular disease [34]. Older patients are more prone to intradialytic hypotension [35], which may relate to myocardial dysfunction and impaired autonomic function [36]. The intradialytic reduction in myocardial blood flow seen during HD [37] could further worsen haemodynamic instability resulting in repeated cycles of end-organ hypoperfusion.…”