Virtual case presentation Patient under dialysis with uncontrolled hypertension Haytham Soliman, MD Fayoum university
Virtual case presentation Patient under dialysis with uncontrolled hypertension
Haytham Soliman, MDFayoum university
History • A 60 years old male
• Diabetic on insulin
• Obese with BMI of 40
• Hypertensive with uncontrolled hypertension
• ESRD due to advanced diabetic nephropathy
Primary care physician
• He requested an ECG denoting only LVH
• This was confirmed by echocardiography showing LVH, grade 2 DD and no decrease in systolic LV functions
• He decided to monitor his blood pressure via office readings once a week 2 hours post dialysis
- Creat : 5 mg/dl- Hb: 10 gm - LDL: 120 - HA1c: 7.5
Treatment • Ramipril 5 mg once• Atenolol 50 mg once • ASA 81 mg once • Atorvastatin 10 mg once • Patient remain uncontrolled with BP: 170/96• His doctor added to him torsemide 40 mg • And still the patient is uncontrolled
Nephrologist • He decided that this patient needs RRT in the form of hemodialysis
• He had a MDM with the primary physician
• They decided to give the patient 2 sessions of dialysis every week
• He did not set a special protocol for this patient in dialysis sessions
Patient • He had a false sensation of safety due to dialysis
• He consumed 6gm of salt per day
• He had no fluid restriction
• He achieved and inter dialysis weight gain of 5 Kg
The result is uncontrolled hypertension and signs of
heart failure
In your opinion What are the fallacies done in this case?
Life style pitfals • Fluid restriction
• Sodium restriction to not more than 2gm/day equivalent to 5 gm table salt per day
• Inter dialysis Weight gain that must not exceed 0.8 kg/ day
Nephrologist • dialysis should be at least three times a week
• total duration should be at least 12 hours per week
• Increase in treatment time and or frequency should be consideredin resistant hypertension
• Daily sessions if feasible helps in reducing BP
• Nocturnal session found to better control BP with less medications
• Special protocol for ultrafiltration of more fluid and usage of less intradialytic sodium must be acquired
EBPG guideline on dialysis strategies. Nephrol Dial Transplant 22 [Suppl 2]: ii5–ii21, 2007
The goal is to reach a Dry Weight• Criteria to determining DW:oNo marked fall in BP during dialysis.oNo hypertension (predialysis BP at the beginning of the week <140/90
mm Hg).oNo peripheral edema.oNo pulmonary congestion on chest X-ray.oCardiothoracic ratio ≤50% (≤53% in females).
Primary health care physician • He did not set a life style modification program to the patient
• He did not offer him a weight reduction program to improve his blood pressure via weight reduction
• No investigations were requested for secondary hypertension specially Reno vascular hypertension
• Blood pressure monitoring :oIts not accurate to depend on one office reading of blood pressure oBP variation in dialysis patient is very common oPredialysis reading over estimate mean BP by 10 mmHg oPost dialysis reading under estimate the mean BP by 7 mmHG oThe best way is either Ambulatory blood pressure monitoring or
home blood pressure readings oA morning and an evening home readings are ideal to monitor blood
pressure
Primary health care physician
• The treatment choice :
o ACE inhibitors and ARBS are the groups of choice for patients with HD They also reduce LV mass and reduces mortality
o Beta blockers are very important in hypertensive patients with dialysis as they tends to improve mortality
o Calcium channel blockers specially Dyhydropiridines are effective for overhydrated state commonly observed in HD patients although there is scanty data about their mortality benefit
o There is no role for diuretics in treating patients with ESRD specially if they are anuric
o High intensity statin therapy must be taken into consideration in such patients with cardiovascular risk and dyslipidemia
Primary health care physician
•Effect of dialysis on antihypertensive drugs:
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 2-3 20-30 12.5 q24h 25-50 q24h Yes
Enalapril 11 prolonged 2.5 q24h or q48h
2.5-10 q24h or q48h
Yes
Fosinopril 12 prolonged 10 q24h 10-20 q24h Yes
Lisinopril 13 54 2.5 q24h or q48h
2.5-10 q24h or q48h
Yes
Ramipril 11 prolonged 2.5-5q24h 2.5-10 q24h yes
Henrich W. Principles and Practice of Dialysis
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
Candesartan 9 ? 4 q24h 8-32 q24h No
Irbesartan 11-15 11-15 75-150 q24h 150-300 q24h No
Losartan 2 4 50 q24h 50-100 q24h NoTelmisartan 24 ? 40 q24h 20-80 q24h No
Valsartan 6 ? 80 q24h 80-160 q24h No
Henrich W. Principles and Practice of Dialysis
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 3.5 3.5 200 q24h 200-300 q24h yes
Atenolol 6-9 <120 25 q48h 25-50 q48h Yes
Carvedilol 4-7 4-7 5 q24h 5 q24h no
Metoprolol 3-4 3-4 50 b.i.d. 50-100 b.i.d. high
Propranolol 2-4 2-4 40 b.i.d. 40-80 b.i.d. yes
Henrich W. Principles and Practice of Dialysis
Blood pressure remaining above goal in spite of concurrent use of 3 antihypertensive agents of different classes.
Resistant Hypertension
Resistant Hypertension you must search for • The use of non steroidal anti-inflammatory drugs
• Renovascular hypertension
• Increasing cysts in polysystic kidney disease
• Concomitant use of erythropoietin therapy
• Presence of sleep breathing disorders
• Compliance
Drugs that can be used in addition • Transdermal clonidine at weekly intervals.
• Minoxidil, a potent vasodilator used with beta blockers
Use of transdermal clonidine in chronic hemodialysis patients. Clin Nephrol 1993;39:32-36
Use of minoxidil in the azotemic patient. J Cardiovasc Pharmacol 1980;2:173-S180
Resistant HTN in ESRD • Renal sympathetic nerve ablation
• Device-Based Therapy for Resistant Hypertension• Baroreflex Activation Therapy• Renal Denervation Therapy
Baroreflex Activation Therapy (BAT)Continuously Modulates the Autonomic Nervous System
Carotid Baroreceptor Stimulation
Heart Vessels Kidney
Inhibit sympathetic &
Enhance Parasymp
HR Vasodilation Natriuresis Renin secretion
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 799–801,2012Circulation. 2002;106:1974–1979
• appears at the end of dialysis when water removal is completed.• Pathogenesis and therapy are not well documented.oUltrafiltrationoHypovolemiaopre-existing hypertensionoHypercalcemiaoImprovement of hypoxiaoantihypertensives that are remove during dialysis.
Paradoxical hypertension
So what we did was: • We advised the patient about life style and diet habits
• We modify the protocols of dialysis including frequency, duration and the amount of sodium
• We offered the patient a new regime for drug therapy stressing upon patient compliance
• We rained the patient for home readings
Aggressive Treatment oValsartan 160 mg o.d oAmlodipine 10 mg o.d oCarvidilol 25 mg o.doAtorvastatin 40 mg o.d
We achieved a goal of 110/70 blood pressure Is it an optimum goal for mortality benefit ?
U shape mortality relation ship • This means that the lower BP is not the better in terms of mortality
benefits
• Among 16,959 dialysis patients in the US, low SBP (120mmHg) was associzated with increased mortality among HD patient
• High SBP (150mmHg) was associated with increased mortality among patients who survived at least 3 years.
Changing relationship of blood pressure with mortalityover time among hemodialysis patients. JAm Soc Nephrol 17: 513–520, 2006
Relationship between BP and mortality in dialysis patients
Zagers’ 1998 reference
In conclusion• Patient with resistant hypertension and HD needs very special care
• Volume restriction and dietary sodium reduction are of most important
• Achieving proper dry weight is very important
• The choice of drugs must be tailored upon patient
• Special care must be taken upon the effect of dialysis upon the antihypertensive drugs
• Too low blood pressure is as harmful as too high blood pressure
Thank you