#28 NephMadness PodCrawl: Blood Pressure and Dialysis

Managing blood pressure for dialysis patient can be complicated. Nephrologists Dr. Daniel Weiner @DanTheKidneyMan and Dr. Bourne Auguste @bourneauguste address intradialytic hypertension and hypotension while giving a huge shout out to the dark horse of nephrology: peritoneal dialysis.

This episode is a part of NephMadness: a nephrology educational initiative that is modeled after the college basketball tournament but with nephrology concepts. It is a noncommercial learning initiative that leverages the tools of social media to teach about the latest and greatest breakthroughs in the field of nephrology!

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BP meds prior to dialysis

Nurses often find themselves in the situation of having to decide whether or not to give their patient antihypertensive medications prior to sending them off to dialysis.

Dr. Weiner and Dr. Bourne’s advice:

  • In general, give:
    • Beta blockers and calcium channel blockers to prevent unstable tachycardias
    • Diuretics to maximize the amount of fluid that can be removed from the patient
  • ACE inhibitors will be dialyzed out
  • Call the nephrologist if in doubt

Intradialytic Hypertension

Patients are losing blood volume during dialysis, so we tend to expect that the BP will fall during. But this isn’t always the case.

Intradialytic hypertensions (an increase in the systolic BP by greater or equal than 10 mmHg or the MAP by greater or equal than 15 mmHg.) occurs in ~5-10% of dialysis patients.

Causes

  • ACE inhibitors are dialyzed out
  • Patient is very fluid overloaded
  • Sympathetic nervous system stimulation (ie stress, pain)

Intradialytic Hypotension

A common problem during dialysis

Causes

  • Autonomic dysfunction (hormones aren’t able to maintain vascular tone in the setting of fluid loss)
    • Diabetes
    • Sepsis
    • Neurologic disorders
  • Malnutrition (unable to keep fluid in vessels)
  • Liver failure

Interventions

  • Take fluid off more slowly
  • Avoid large meals during dialysis (reduce pooling of blood to gastric areas)
  • Add volume back with NS
  • Albumin
  • Vasopressors (if requiring 2+ pressors, patient will likely switch to CRRT)
  • Peritoneal dialysis!

A Plug-In for Peritoneal Dialysis

Peritoneal Dialysis in the United States: Lessons for the Future (Hansson, 2020)