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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Marked decrease (> 30 mm Hg systolic) in blood pressure or a systolic blood pressure of < 90 mm Hg during dialysis

  • Symptoms of decreased cerebral perfusion

GENERAL CONSIDERATIONS

  • More common in those with diabetes, atherosclerosis, and hypertension

  • Usually occurs in the setting of aggressive ultrafiltration to reduce intradialytic weight gain

  • Hypotension limits the achievement of diuresis during dialysis

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Symptoms of decreased cerebral perfusion:

    • – Somnolence

    • – Dizziness

    • – Syncope

PHYSICAL EXAM FINDINGS

  • Systolic blood pressure drop of > 30 mm Hg or systolic blood pressure < 90 mm Hg

  • Cool clammy skin

DIFFERENTIAL DIAGNOSIS

  • Pericardial effusion due to uremia or other causes

  • Left ventricular diastolic dysfunction due to hypertrophy

  • Autonomic dysfunction, often due to diabetes

  • Myocardial ischemia or infarction (may be produced by hypotension also)

  • Overzealous use of antihypertensive agents

  • Cardiac arrhythmias

  • Severe left ventricular systolic dysfunction

  • Low dry weight of patient

  • Decreased plasma osmolarity

  • Splanchnic vasodilation due to a large meal

  • Characteristics of the dialysate (eg, acetate)

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • CBC: anemia frequently a contributing factor

ELECTROCARDIOGRAPHY

  • Left chamber enlargement signs

  • Cardiac arrhythmias

IMAGING STUDIES

  • Echocardiography:

    • – Usually shows left ventricular hypertrophy and left atrial enlargement

    • – Reduced systolic left ventricular function may be present

TREATMENT

CARDIOLOGY REFERRAL

  • When simple measures do not correct the problem

  • Suspected cardiac disease

HOSPITALIZATION CRITERIA

  • Inability to safely dialyze

MEDICATIONS

  • Identify and treat myocardial ischemia

  • Carefully adjust antihypertensive medications

  • Prevent cardiac arrhythmias

  • Treat heart failure

  • Administer vasoconstrictors in refractory cases

THERAPEUTIC PROCEDURES

  • Myocardial revascularization when appropriate

  • Identify and remove pericardial fluid if present

MONITORING

  • Blood pressure during dialysis

  • ECG as appropriate

DIET AND ACTIVITY

  • Renal disease diet

  • Low-fat diet

  • Activity as tolerated

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • Resolution of problem

FOLLOW-UP

  • According to dialysis routine

  • As appropriate for underlying diseases

COMPLICATIONS

  • Myocardial infarction

  • Stroke

  • Cardiac arrhythmias

  • Death

PROGNOSIS

  • In general, hypotension during dialysis is a poor prognostic sign

PREVENTION

  • Decrease fluid removal in patients with low dry weight

  • Adjust sodium in dialysate to > 135 mmol/L to prevent hypo-osmolarity

  • Use cooled bicarbonate dialysate

  • Frequent shorter dialysis sessions with less aggressive ultrafiltration

  • Nocturnal dialysis

RESOURCES

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