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Dr. Abdulkareem Alsuwaida Associate Professor King Saud University Hemodialysis Symposium 08-09 February 2014 Al Madinah AlMunawwarah.

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Presentation on theme: "Dr. Abdulkareem Alsuwaida Associate Professor King Saud University Hemodialysis Symposium 08-09 February 2014 Al Madinah AlMunawwarah."— Presentation transcript:

1 Dr. Abdulkareem Alsuwaida Associate Professor King Saud University Hemodialysis Symposium February 2014 Al Madinah AlMunawwarah

2 Prevalence of hypertension in chronic HD pts (N=65393, mean age 61 yr, mean duration on HD 8 yr) Iseki et al. Ther Apher Dial 2007;11:

3 Death Due to Strokes and Heart Disease SYSTOLIC BLOOD PRESSURE mm Hg stroke deaths Heart deaths Stroke 168< Heart

4 Stidley et al. J Am Soc Nephrol 2006;17: Unadjusted survival by baseline predialysis systolic BP

5 “Reverse-epidemiology” Low BP is a consequence of other disease: Major CVD Malnutrition-inflammation-atherosclerosis complex LVD

6 Mechanism of HTN Sodium and volume overload. Sympathetic nervous system activity Inappropriate renin secretion. Alteration in endothelin and nitric oxide. Erythropoietin therapy. Hyperparathyroidism. Other: Uremic toxins, Nocturnal hypoxemia and sleep disturbances Nephrol Dial Transplant May; 19(5):

7 Mechanism of HTN Hypervolemia is the major factor Positive Sodium balance Increases intake and decreased excretion Achieving DW will control 60% of cases of HTN Assessment of DW Am J Kidney Dis Aug; 28(2):257-61

8 Mechanism of HTN Renin inappropriately high for ? etiology. Increase vascular resistance Increased in sympathetic activity Originate from kidneys Uremic metabolites that activate chemoreceptors within the kidney Increase vascular resistance and systemic BP

9 When and How to measure the BP in dialysis patients? Dialysis Unit: During, Before, or After Home BP ABPM

10 When and How to measure the BP in dialysis patients? Predialysis SBP overestimated mean SBP by an average of 10 mm Hg Postdialysis SBP underestimated mean SBP by an average of 7 mm Hg BP reasings over a period of 1 to 2 weeks rather than isolated readings should be used

11 Home blood pressure monitoring is of greater prognostic value than hemodialysis units recordings Alborzi et al. CJASN 2007;2:

12 When and How to measure the BP in dialysis patients? Interdialytic ABP monitoring best represent BP in dialysis patients. Only method that will show diurnal variation Difficult to repeat, Vascular access Home BP

13 Relationship between BP and mortality in dialysis patients Luther JM Kidn Int 2008;73:

14 Target blood pressure? Scarcity of evidence Pre-dialysis BP < 150/90 ABPM < 140/85 Avoid drop of SBP greater than 30 mm Hg or post dialysis postural hypotension. Increase mortality and hospitalization < 110/60 mm Hg correlates significantly with the risk of death within 5 years Kidney Int 2007;71: 454–61. Kidney Int 2004;66:1212–20. Am J Kidn Dis. 2005;45

15 ABPM systolic BP and mortality. Agarwal R Hypertension. 2010;55:

16 Management of Hypertension Step 1: Lifestyle modifications and control of volume status with lifestyle modifications. Step 2: Control of volume status with dialysis. Step 3: Administration of antihypertensive drugs.

17 Life style modifications Body weight: 'obesity paradox‘ Mainly explained by mal-or undernutrition. Low salt intake 1000 to 1500 mg of sodium/day Exercise

18 Life style modifications Tobacco use 59% more CHF 68% more PVD Mortality 37% Foley et al. Kidney Int 2003; 63:

19 Life style modifications

20 Management of Hypertension Control of volume status Limit interdialytic weight gain a 2.5 kg is associated with a significant increase in BP Achieve dry weight Frequent dialysis & Longer dialysis time Agarwal R, et al. Hypertension Mar; 53(3):500-7.

21 Dry Weight Criteria to determining DW: No marked fall in BP during dialysis. No hypertension (predialysis BP at the beginning of the week <140/90 mm Hg). No peripheral edema. No pulmonary congestion on chest X-ray. Cardiothoracic ratio ≤50% (≤53% in females).

22 Dry-weight reduction in hypertensive hemodialysis patients (DRIP): a randomized, controlled trial. Agarwal R, et al. Hypertension Mar; 53(3):500-7.

23 Antihypertensive drugs 160/95 mmHg immediate before the next dialysis session Campese VM TA. Hypertension in dialysis patients All classes of antihypertensive can be used in dialysis patients (Except diuretics). Compelling indications are similar

24 Treatment of Hypertension ARBs and ACE are the preferable first line of antihypertensive drugs Prevent left ventricular hypertrophy Cannella G etal.Am J Kidney Dis Nov; 30(5): Suzuki H et al. Am J Kidney Dis Sep; 52(3):501-6.

25 Pharmacokinetic properties of ACE Inhibitors in ESRD T1/2(h) normal T1/2(h) ESRD Initial dose in HD Maintenance dose in HD Removal during HD Captopril q24h25-50 q24hYes Enalapril11prolonged2.5 q24h or q48h q24h or q48h Yes Fosinopril12prolonged10 q24h10-20 q24hYes Lisinopril q24h or q48h q24h or q48h Yes Ramipril11prolonged2.5-5q24h q24hyes Henrich W. Principles and Practice of Dialysis

26 Pharmacokinetic properties of ARB’s in ESRD T1/2(h) normal T1/2(h) ESRD Initial dose in HD Maintenance dose in HD Removal during HD Candesartan9?4 q24h8-32 q24hNo Irbesartan q24h q24hNo Losartan2450 q24h q24hNo Telmisartan24?40 q24h20-80 q24hNo Valsartan6?80 q24h q24hNo Henrich W. Principles and Practice of Dialysis

27 Pharmacologic properties of β-blockers in chronic dialysis patients T1/2(h) normal T1/2(h) ESRD Initial dose in HD Maintenance dose in HD Removal during HD Acebutolol q24h q24hyes Atenolol6-9<12025 q48h25-50 q48hYes Carvedilol4-7 5 q24h no Metoprolol b.i.d b.i.d.high Propranolol b.i.d b.i.d.yes Henrich W. Principles and Practice of Dialysis

28 Hypertension in hemodialysis patients treated with atenolol or lisinopril: a randomized controlled trial. Agarwal R et al NDT 2014 ESRD with LVH lisinopril (n = 100) or atenolol (n = 100) each administered three times per week after dialysis. Results: Hospitalizations for heart failure were worse in the lisinopril group (IRR 3.13, P = 0.021). All-cause hospitalizations were higher in the lisinopril group [IRR 1.61 (95% CI , P = 0.002)].

29 Blood pressure remaining above goal in spite of concurrent use of 3 antihypertensive agents of different classes. Resistant Hypertension

30 Resistant HTN in ESRD Transdermal clonidine at weekly intervals. Minoxidil, a potent vasodilator, used with beta blockers Spironolactone in Hemodialysis Patients mg post dialysis Risk of hyperkalemia Improve EF and Improve BP control Large studies are done

31 Resistant Hypertension The use of non steroidal anti-inflammatory drugs Renovascular hypertension Increasing cysts in polysystic kidney disease Compliance

32 Resistant HTN in ESRD Renal sympathetic nerve ablation Hyperactivation of the sympathetic nervous system J Clin Hypertens (Greenwich) Nov;14 The Future? Device-Based Therapy for Resistant Hypertension Baroreflex Activation Therapy Renal Denervation Therapy

33 Baroreflex Activation Therapy (BAT) Continuously Modulates the Autonomic Nervous System Carotid Baroreceptor Stimulation HeartVesselsKidney Inhibit sympathetic & Enhance Parasymp HRVasodilationNatriuresis Renin secretion

34 Anatomical Location of Renal Sympathetic Nerves Arise from T10-L1 Follow the renal artery to the kidney Primarily lie within the adventitia The Journal of Clinical Hypertension. 14, pages 799–801,2012 Circulation. 2002;106:1974–1979

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36 Intradialytic hypertension 5-15% Mechanism Extracellular volume overload Increased cardiac output Changes in sodium levels Activation of the renin–angiotensin–aldosterone system Overactivity of the sympathetic nervous system Endothelial cell dysfunction. Removal of anti HTN during dialysis

37 Intradialytic Hypertension The most important treatment is adequate sodium and water removal and reducing sympathetic hyperactivity. Changing to non-dialyzable antihypertensive medications Altering the dialysis prescription.

38 Summary Sodium excess and extracellular volume expansion is the major factor in the development of hypertension. Lifestyle modifications is critical. Control of volume status (Dietary salt and fluid restriction). Correcting adequately volume expansion with dialysis. All classes of antihypertensive drugs can be used in dialysis patients

39 Thank You


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