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