Hypertension during dialysis

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Specializes in Dialysis.

Interesting post over on the renal fellow blog about a pt whose HTN became worse during dialysis. 15% of all pts experience this during dialysis. Multiple causes but adjusting the current hypertension meds, lengthening treatment time and adjusting the dialysate sodium helped this patient.

Renal Fellow Network

(second posting down the page on the blog)

Key points:

-volume overload

-renin-angiotensin-aldosterone over activation

-endothelial dysfunction (rises in the vasoconstrictor endothelin-1)

-sympathetic over activation

-EPO-related

-net sodium gain during dialysis (hyponatremic patients dialyzed with high sodium bath)

-electrolyte disturbances (hypokalemia and hypercalcemia)

-dialytic removal of antihypertensives: agents that are significantly removed during dialysis include atenolol, metoprolol, lisinopril and enalapril. ARB, labetolol, carvedilol, ramipril, hydralazine, benazepril, clonidine and hydralazine and calcium-channel blockers have little clearance during dialysis (figure above)

Rx:

-increase time of dialysis with more gentle ultrafiltration

-attempt to lower dry weight

-review antihypertensives to favor those not eliminiated on dialysis

-consider adding ACEI/ARB

-if hyponatremia, lower sodium of dialysate

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