Falls in systolic blood pressure during dialysis which require no nursing intervention are associated with increased patient intra-dialytic symptom self-reporting and prolonged post-dialysis recovery times

Abstract

Background: Haemodialysis (HD) patients may suffer symptoms during dialysis and take time to recover post HD. We wished to determine whether patients with symptomatic intra-dialytic hypotension (IDH), requiring nursing interventions, or an asymptomatic fall in systolic blood pressure (SBP) reported more symptoms during dialysis. Methods: Six hundred three HD patients completed self-reported intra-dialytic symptom questionnaires and recovery using a visual analogue scale, which were compared with their dialysis session records. Results: Twenty-nine (4.8%) of patients suffered symptomatic IDH, and 187 (31.0%) had a fall in SBP of > 20 mmHg. Symptomatic patients had greater total symptom scores (30 (23-44) vs 23 (10-38), p < 0.05, versus asymptomatic patients, with increased low blood pressure, dizziness, cramps, palpitations and feeling cold reported (all p < 0.05). Patients with a SBP fall of > 20 mmHg had greater total scores compared with those with a SBP increase of > 10 mmHg (26 (13-38) vs 17 (7-34), p < 0.05), with more dizziness, cramps, backache, shortness of breath and headache reported (all p < 0.05). Although ultrafiltration rates were similar, HD weight loss was greater for patients with a SBP fall of > 20 mmHg (2.5 ± 1.1 vs 2.0 ± 1.3%, p < 0.05). Patients with highest symptoms scores (highest vs lowest quartile) had longer recovery times (40.3 vs 7.6% > 4 h), p < 0.001. Multivariable analysis showed that patients reporting more intradialytic symptoms had higher psychological distress thermometer scores (odds ratio (OR) 1.34 (95% confidence limits 1.26-1.44)), systolic blood pressure < 100 mmHg (OR 2.53 (1.04-6.1)), whereas symptom scores were lower for male gender (OR 0.34 (0.22-0.51)), and with increasing age (OR 0.99 (0.97-0.99)). Conclusion: Patients with both symptomatic and asymptomatic IDH, self-reported more symptoms during dialysis, and those patients reporting more symptoms had longer recovery times. We found that younger, female patients, those with greater psychological distress, and lower systolic blood pressure self-reported more intra-dialytic symptoms. More attention is required to prevent falls in intra-dialytic blood pressure to improve the patient experience of HD and shorten post-dialysis recovery times.

Patient-reported symptoms during dialysis: the effect of pre-dialysis extracellular water and change in extracellular water post-dialysis

“…This group had similar percentage weight loss and ultrafiltration rates compared to the other groups yet dialysed using a higher dialysate sodium and a lower gradient between the serum and dialysate sodium. Previous studies have suggested that using a higher dialysate sodium and a lower serum to dialysate gradient reduces patient symptoms [34], but our study does not support these earlier reports. However, as we used cooled dialysates, then this may have reduced any potential effect of dialysate sodium.…”

“…However, neither total dialysis symptom score nor any individual symptom score was greater in those patients with the greatest fall in aECW, and similarly, there was no effect on post-dialysis recovery time, and this is supported by a recent retrospective analysis [30]. Although one would expect that a fall in systolic blood pressure during dialysis would be associated with more intra-dialytic symptoms, studies have observed that patients starting dialysis with higher blood pressures and with more volume to be removed reported fewer symptoms [30,34]. This may reflect that although blood pressure fell, those who were symptomatic started dialysis with lower blood pressures, so the effect of a subsequent reduction led to greater symptom reporting.…”

Dialysis recovery time: associated factors and its association with quality of life of hemodialysis patients

“…In the current work, we found no association between the pre-HD MAP and the DRT; however, we found a negative correlation between the post-HD MAP and the change in the MAP on one hand and the DRT on the other. Similar findings were reported by Yoowannakul et al [ 45 ]. The drop in the blood pressure during HD leads to a reduction in the blood supply to the vital organs like the heart, brain, and mesenteries, which might explain the increase in the number of reports of backache with HD, in addition to the increased frequency of headache, dizziness, breathlessness, and cramps.…”

Reducing the risk of intradialytic hypotension by altering the composition of the dialysate

“…Both symptomatic and asymptomatic IDH is associated with significant dialysis patient morbidity both in the short and long term, 55,56 and increased risk of mortality 4 . In the short term, choosing a dialysate with a higher sodium, magnesium, and calcium concentration and lower temperature reduces the risk of IDH.…”