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Intradialytic hypertension (HTN) is observed in pregnant patients requiring hemodialysis (HD). Physiologic mechanisms of this phenomenon are not well understood, and guidelines are scarce on the management of intradialytic HTN in this population.
We report two pregnant patients with advanced chronic kidney disease (CKD) of various etiologies requiring HD during their pregnancies. Both patients presented with obstetric severe range blood pressures (>160/110 mmHg) during HD sessions, which overall improved on non-dialysis days. The first patient was a 32-year-old at 24 weeks gestation with chronic HTN, CKD-4 secondary to obstructive uropathy and status post bladder augmentation admitted for suspected superimposed pre-eclampsia with severe features. She initiated daily HD due to azotemia and hyperkalemia; her initiation BUN was 56 mg/dL. Her hypertension was treated with long-acting antihypertensive regimen of oral nifedipine and labetalol. Her blood pressures were overall controlled on non-dialysis days; however, she intermittently required IV labetalol during dialysis sessions for persistent severe hypertension. Ultimately, she delivered early preterm at 26 weeks gestation for worsening severe preeclampsia. The second patient was a 36-year-old at 27 weeks gestation with chronic HTN, CKD-5 secondary to IgA nephropathy, initiated on HD during the second trimester due to azotemia. She was managed with clonidine patch, oral labetalol and nifedipine. She experienced severe intradialytic HTN with the majority of her sessions, requiring frequent IV hydralazine and labetalol. She underwent preterm delivery at 30 weeks gestation for worsening hypertension. Both patients continued HD postpartum and no longer experienced intradialytic HTN. Additionally, their anti-hypertensive regimens were down titrated postpartum.
Intradialytic severe HTN occurred during HD sessions for both patients, while they were overall non-severe on non-dialysis days. Both patients required up titration of oral antihypertensive regimens, and as needed IV antihypertensive medications to treat severe HTN during HD. Ultimately, intradialytic HTN was a contributing factor to their preterm deliveries.
Intradialytic HTN can occur in pregnant patients. The mechanism of this phenomenon is uncertain, but data on intradialytic HTN on non-pregnant HD patients suggest endothelial cell dysfunction may play a role. This dysfunction is noted in the pathophysiology of preeclampsia, suggesting correlation between preeclampsia and intradialytic HTN. Guidelines and further studies on intradialytic HTN on pregnant patients requiring HD are needed. Management includes increasing the dose of oral antihypertensive medications plus IV antihypertensive medications. Based on this limited series, the intradialytic severe HTN may resolve postpartum.