THE RELATIONSHIP BETWEEN PRE-DIALYSIS ORTHOSTATIC HYPOTENSION AND BLOOD PRESSURE DURING MAINTENANCE HEMODIALYSIS

 

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THE RELATIONSHIP BETWEEN PRE-DIALYSIS ORTHOSTATIC HYPOTENSION AND BLOOD PRESSURE DURING MAINTENANCE HEMODIALYSIS

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Leszek
Pstras
Leszek Pstras lpstras@ibib.waw.pl Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences Department of Modeling and Supporting of Internal Organs Functions Warsaw Poland *
Simon Correa scorreagaviria@bwh.harvard.edu Brigham and Women's Hospital Renal Division, Department of Medicine Boston, MA United States - Harvard Medical School Boston, MA United States
Finnian Mc Causland fmccausland@bwh.harvard.edu Brigham and Women's Hospital Renal Division, Department of Medicine Boston, MA United States - Harvard Medical School Boston, MA United States
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Orthostatic hypotension (OH) – an excessive drop in blood pressure (BP) upon standing – and intradialytic hypotension – an excessive drop in BP during hemodialysis (HD) – are both associated with higher all-cause mortality and can be attributed to similar factors, which may include impaired autonomic reflexes, blood volume depletion, or cardiac dysfunction. However, data on the association between OH and the BP response during HD are limited.

This was a sub-analysis of a prospective cohort study on 50 maintenance, thrice-weekly HD patients admitted to Brigham and Women’s Hospital in Boston, MA, USA. The analysis included 20 patients in whom OH was assessed 5 to 60 mins before HD by measuring BP (using a calibrated upper-arm cuff) in the supine position (after at least 5 mins of rest) and then at 1, 3, and 5 mins after standing. OH was defined as a decrease in systolic BP (SBP) by at least 20 mmHg or below 90 mmHg, or a decrease in diastolic blood pressure (DBP) by at least 10 mmHg, within 3 minutes of standing. In patients with baseline supine SBP>140 mmHg, a threshold decline of 30 mmHg was used. In 5 patients who were unable to stand, BP was measured in the sitting position. BP was then measured before and every 15 min during subsequent HD (lasting approximately 4 hours).

Of the 20 studied patients (9 females), median age was 65 years, and median BP in the supine position was 135/63 mmHg. Pre-dialysis OH was observed in 12 patients (60%, 5 females), including 4 patients who sat instead of standing up. No significant differences were found between the OH and non-OH groups in terms of supine BP, age, diagnosis of hypertension, heart failure, or diabetes, BP medications, or dialysis prescription parameters. Patients from the OH group tended to have lower DBP before and throughout HD and lower SBP during most of HD (see Figure 1); however, significant differences were found only for DBP before HD (median 65 mmHg in the OH group vs 80 mmHg in the non-OH group, P=0.049) and for DBP at 120 min into HD (57 mmHg vs 76 mmHg, P=0.048). In the non-OH group, SBP remained relatively stable through most of HD and only decreased significantly after around 165 min (median 124 vs 136 mmHg pre-HD, P=0.03). In the OH group, SBP showed a significant decrease during HD already after 30 min (129 vs 144 mmHg pre-HD, P=0.02) and a further decrease after 120 min (104 vs 134 mmHg pre-HD, P=0.03).

Figure1

Figure 1. Pre- and intra-dialytic levels of systolic blood pressure (SBP) and diastolic blood pressure (DBP) in patients with (red solid lines) or without (black dashed lines) orthostatic hypotension (OH) observed before the studied hemodialysis session. Data presented as medians and interquartile ranges.

Patients with pre-dialysis OH had earlier and greater decreases in SBP during HD compared to patients without OH, suggesting a greater susceptibility to intradialytic hypotension. They also tended to have lower DBP before and during HD. Larger studies are needed to confirm and further investigate these associations.

Kewords