Plasma concentrations of adrenomedullin and ghrelin in hemodialysis patients with sustained and episodic hypotension

Intradialytic Hypotension as an Independent Risk Factor for Long-Term Mortality in Maintaining Hemodialysis Patients: A 5-Year Follow-Up Cohort Study

AIMS

This study aimed to assess risk factors of intradialytic hypotension (IDH) and the association of prognosis and IDH among maintenance hemodialysis (MHD) patients.

METHODS

Among 293 patients, 117 were identified with IDH (more than 4 hypotensive events during 3 months). The association between IDH and survival was evaluated.

RESULTS

The incidence of IDH was 39.9%. Age, ultrafiltration rate, N-terminal pro-B-type natriuretic peptide (NT-proBNP), albumin, β2-microglobulin (β2MG), and aortic root inside diameter (AoRD) were independently associated with IDH. During the 5-year follow-up, 84 patients died with a mortality rate 5.2 per 100 person-year. IDH-prone patients had a higher all-cause mortality rate. IDH and left ventricular mass index were independent risk factors for death (HR 1.655, 95% CI 1.061-2.580; HR 1.008, 95% CI 1.001-1.016).

CONCLUSION

IDH is an independent risk factor for long-term mortality in MHD patients. Patients with older age, high ultrafiltration rate, high level of serum NT-proBNP and β2MG, hypoalbuminemia, and shorter AoRD are at high risk of IDH.

Rapid resolution of severe sustained low blood pressure in haemodialysis patients after successful renal transplantation

BACKGROUND

Low blood pressure occurring in the absence of volume depletion, anti-hypertensive medication, heart failure or cortisol deficiency occurs in ~5-10% of haemodialysis patients, and can result in serious complications. The pathophysiology of this syndrome is poorly understood.

METHODS

We describe eight cases with dialysis-associated hypotension who underwent renal transplantation. Four patients were severely hypotensive with a systolic blood pressure (SBP) <100 mmHg before and during dialysis, and four had a SBP usually <100 mmHg during dialysis, but usually >100 mmHg between sessions. All had donor-specific human leukocyte antigen antibodies. Six patients underwent pre-transplant plasmapheresis, which was curtailed in two because of further falls in blood pressure. Two patients experienced clotting of their arteriovenous fistula. In one patient cryofiltration was used, which was tolerated without severe falls in the BP. The remaining patient, who had hypotension-associated retinal vein thrombosis before transplant, was supported with an epinephrine infusion and did not receive plasmapheresis.

RESULTS

Post-transplant, the first patient did not receive pressor therapy and died from bowel ischaemia. The other seven patients were supported with inotropes on critical care. The administration of steroids did not reverse hypotension. The mean pre-treatment SBP was 96 mmHg (range 71-110, SEM 5.0). After inotropes were withdrawn and graft function was established, the mean SBP was 127 mmHg (range 113-149, SEM 4.9) (P < 0.01).

CONCLUSIONS

Renal transplantation was performed successfully and safely in patients when pressor therapy was used to treat severe dialysis-associated hypotension and, moreover, the blood pressure normalized rapidly after graft function was established.

Serum vasopressin response in patients with intradialytic hypotension: a pilot study

BACKGROUND AND OBJECTIVES

Arginine vasopressin (AVP), an endogenous hormone with vasopressor properties, may be inadequately secreted during episodes of intradialytic hypotension (IDH).

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

To evaluate this, we performed a prospective, observational pilot study of 20 chronic hemodialysis patients assessing the baseline AVP level and trend of AVP with ultrafiltration in patients with a diagnosis of IDH compared with patients without IDH. Ten symptomatic IDH patients and 10 controls were enrolled and matched for age, gender, and dialysis vintage. AVP levels were obtained hourly throughout the dialysis session and during hypotensive episodes.

RESULTS

We observed that IDH patients experienced greater decreases in both systolic and diastolic blood pressure during the dialysis session despite equivalent ultrafiltration in both groups. AVP concentration did not increase in the IDH patients (5.0 +/- 1.8) compared with controls (6.4 +/- 6.0) (P = 0.5) despite hypotensive events.

CONCLUSIONS

This study suggests that symptomatic IDH patients are unable to mount an appropriate increase in AVP secretion in the setting of hypotension. These findings support the possibility of AVP as a mechanism driven therapy for patients with symptomatic IDH.