Impact of drugs on intradialytic hypotension: Antihypertensives and vasoconstrictors

Abstract

Intradialytic hypotension (IDH) is a common complication of hemodialysis and is associated with numerous adverse outcomes including cardiovascular events, inadequate dialysis, loss of vascular access, and death. It is estimated that approximately 20%–30% of all dialysis sessions are affected by IDH. In seeking ways to reduce the occurrence of IDH, dialysis providers often turn to pharmacological approaches: withholding antihypertensive medications prior to hemodialysis or administering vasoconstrictor medications. This review will focus on what is known about the relation between antihypertensive medications and IDH, and summarize studies that have examined the efficacy of vasoconstrictor medications on IDH, including midodrine, arginine vasopressin, and droxidopa. However, there is currently scant evidence that any pharmacological approach is particularly effective in reducing IDH. Additional studies of potential treatments for IDH are needed, and should examine not only hemodynamic effects such as changes in nadir blood pressure during dialysis, but also on patient-centered and clinical outcomes such as symptoms of IDH, quality of life, and cardiovascular events.

Blood pressure and volume management in dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

“…Nonmedication strategies for treating intradialytic hypotension, such as cardiovascular status optimization, UF rate minimization, and target-weight reassessment, should be prioritized. Medication options include midodrine, 71 arginine-vasopressin, [72][73][74][75][76] sertraline, 77,78 droxidopa, amezinium metilsulfate, 79 fludrocortisone, and carnitine. 71 In general, the evidence base for these strategies is relatively weak, with most studies being small and of short duration.…”

“…Medication options include midodrine, 71 arginine-vasopressin, [72][73][74][75][76] sertraline, 77,78 droxidopa, amezinium metilsulfate, 79 fludrocortisone, and carnitine. 71 In general, the evidence base for these strategies is relatively weak, with most studies being small and of short duration. 71 The most widely used is midodrine, an oral vasoconstrictor, although efficacy data are limited, 65 as is its availability outside the US (Table 3).…”

Mechanisms, Clinical Implications, and Treatment of Intradialytic Hypotension

“…On the one hand, medications that result in negative inotropy and chronotropy may lead to more IDH; on the other hand, slowing of heart rate and improved ventricular compliance may augment diastolic filling and minimize IDH. As outlined in a recent review of this topic, despite a paucity of prospective evidence on the optimal combinations and timing of antihypertensive medications in patients on hemodialysis, individualized adjustment in an attempt to minimize IDH may be considered for select patients (27).…”

Peritoneal dialysis has optimal intradialytic hemodynamics and preserves residual renal function: Why isn't it better than hemodialysis?

“…43 Most but not all reports have linked glucose absorption with the development of insulin resistance in nondiabetic patients on PD, 32,44,45 driven by higher levels of insulin, fasting plasma glucose, and triglycerides. 46 Additionally, a multicenter, open-label randomized study showed that lowering the glucose content of an automated PD regime resulted in lower insulin resistance at 90 days. 47 Insulin resistance is also associated with higher rates of cardiovascular disease.…”