Treatment Options for Intradialytic Hypotension

By Peter Laird, MD

The Renal Fellow Network is an excellent source of information on nephrology issues written by a doctor going through his own renal fellowship training. It has become a favorite part of my own day to catch up on what new and interesting topic he will discuss with one new topic devoted every day.

Yesterday's post is on treatment options for low blood pressure during dialysis sessions. This is a very common problem in American dialysis units, especially in those that treat with high blood flow rates, high flux filters and short dialysis times. He discusses several options for reducing these episodes during dialysis. From a technical point of view, they are useful adjuncts for treating patients subject to this complication, but he fails to discuss the most important aspect of intradialytic hypotension, why it happens in the first place.

Thus, I take issue with his response from three separate arenas. First, he does not address the most important factor which is dietary salt control in those patients that end up needing higher ultrafiltration rates to maintain their stated dry weight. Preventing the need for higher ultrafiltration rates encumbered by elevated sodium intake should be number one on the list for treating what is a chronic complication in many dialysis patients as Bill and Anna have recently commented on (here and here).

Reviewing all of his remedies for low blood pressures during dialysis we see once again the American bias to problems caused by an inadequate level of dialysis in the first place. Longer dialysis sessions in Europe, Japan and Australia avoid most of America’s complications caused by our unique rapid ultrafiltration rates during short sessions of 2.5 - 3 hours that most patients are subjected to. Simply lengthening the same fluid removal over a longer period of time will eliminate the majority of hypotensive events caused by this overly aggressive approach to dialysis.

With over forty years of observational studies in America and around the world, it's our short and fast paced dialysis regimens that should be a prime suspect for causing our last place ratings internationally. The US's poor CKD5 outcomes should challenge all American nephrologists to reexamine what can only be judged an unsuccessful approach. Yet, with this short treatise on intradialytic hypotension, it appears that those in training today still have not grasped the underlying causative factors leading to these hypotensive events in the first place. Why treat a complication that could be avoided in the first place?

Second, the entire issue of intradialytic hypotension is intertwined with the elevated risk of LVH/CHF due to issues of blood pressure control as well as elevated interdialytic fluid weight gains. The long term effects of poor fluid control leads to LVH and subsequent increased risk of sudden cardiac death. The European, Japanese and Australian first line remedy for this is to increase frequency of dialysis above 3.5 times per week, or increase the total weekly duration with a concomitant reduction in blood pump speed and ultrafiltration rate. Once again, comparing the American approach as found in this short treatise in the Renal Fellows Network to that of our colleagues overseas, we do not find a single remedy that will improve the longevity of the patients that they are caring for while quotidian dialysis regimens will.

Lastly, quotidian dialysis regimens in whatever form completely eliminate intradialytic hypotension for all practical purposes. Although I do enjoy the materials that this nephrologist in training presents on his site and I value greatly all that I learn from his efforts, I am also equally appalled by the complete avoidance of dialysis related issues that we have learned from our international colleagues. While I would give most of his articles very high marks, the current article on intradialytic hypotension falls short by failing to correlate causative factors with long term treatment options shown to eliminate this problem in the first place as we have learned from the many articles on quotidian dialysis.

It is time for American nephrology programs to take notice of the simple truths of those that keep their patients alive longer than we do here in America. Intradialytic hypotension is a direct complication of rapid, violent fluid removal by short and high intensity dialysis regimens especially in the frail and elderly patient with LVH from chronic fluid overload. It is time to mellow out and slow down our dialysis protocols and then every single remedy listed in the article in question would never need to be considered at all since the problem would no longer exist except on rare occasions. Until American nephrologists recognize that many of the usual complications of dialysis are actually caused by our failed approach to dialysis, we will continue to chase our tails treating that which we should instead prevent.

Comments

[Simon Prince DO, FACP, FASN]

I disagree. I think we understand this phenomena quite well. Lifestyle modification of any sort is, as I am sure you know.. much easier said than done. I strugle with my patients intradialytic weight gain on nearly a daily basis. They all know hey shouldnt drink and keep dietary Na to a minimum.. but nevertheless show up 4+ kg up from their last treatment. They get bombarded with input from the nephrologist, the dietician and the nurses/ techs weighing them in each session.

We nephrologists try... and I hate to punt this back to the patient because I surely wouldnt want to trade places... But, I don't think it is fair to blame the nephrologist because grown adults can't stick to their dietary restrictions. It isnt from lack of knowledge or training that patients gain too much weight in between sessions. It is because they refuse to curtail their intake and continue to eat the way they have for all the years they have pre-dialysis (fast food and all)... despite being told they shouldnt.

[Bill Peckham]

I think rather than trying to bend patients to fit a short infrequent dialysis regime we should be bending the dialysis schedule to fit the patient.

Are these patients who have trouble controlling fluid offered longer runs? Forth runs? Incenter nocturnal? If someone is showing up for a three hour treatment 4+ kg over dry weight I would say the problem isn't the 4+ kg, the problem is the brevity of the treatment.

[Simon Prince]

I think that is a great idea in theory Bill... But unfortunately, the reality is that the economics and scheduling limit time length (a patient just can't stay for an extra hour or so, if there is another patient who needs to get on the machine.. or the unit needs to close). Plus, most patients do not want more time. Most of the time I find it a struggle to get patients to stay 4 hours/ session. Asking them to stay longer or come back for a 4th session is something most patients I know are not in favor of. I think the focus should be on limiting the weight gain, so the patients have easier treatments and are better off.

[Bill Peckham]

The economics and scheduling don't constrain treatment lengths (aside from if a single unit has an unfavorable payer mix and/or is in a state with unreasonable Medicaid rules - units like Lori's who have my sympathy). The LDOs, who can spread payer mix and Medicaid risk, are not so constrained.

It is true that most patients don't want to be on dialysis at all but once they decide to live with CKD5 using dialysis then the job is to make their CKD5 as small a burden as is practicable. Time actually dialyzing is only a piece of the CKD5 burden.

The greatest burden that comes with CKD5 is the ill health that is experienced by too little medicine, too little dialysis. Short, infrequent treatments continue a dynamic where dialysis becomes the disease; people see themselves as "having dialysis" rather than needing dialysis for their CKD5. As things stand today I don't doubt people think they can minimize their CKD5 burden by minimizing the time they spend on dialysis, that's where information and education can serve a vital role.

The new conditions for coverage require all units to tell all patients about all treatment options. Even if those treatment options are not offered by a particular unit. There will be many interesting conversations this year when units have to tell people on three hour dialysis how all their symptoms of under dialysis could be relieved if they received a proper dose of dialysis.

[Simon Prince]

I wish more patients had your point of view. I wholeheartedly agree with it.. there is not one instance that in which I would prefer my patients to do less dialysis. I truly believe more is better.

Unfortunately, my experience is that most of the patients I come into contact with are not as enlightened and receptive to the concept of more dialysis being beneficial. It is truly a struggle on multiple fronts and it is rare that the patient pushes for extra dialysis despite being counseled on its benefits.

[Peter Laird, MD]

Dr. Prince, thank you greatly for your excellent comments. I have addressed some of the physiology issues in another post that should be released shortly.

Aside from the compliance issues with patients that are eating excessive amounts of salt, which is easy to do even when we try to adhere to low salt diets, the economic incentives against physiologic dialysis are another barrier to overcome. I would hope that we can count you and many of your colleagues as partners in DSENs crusade for optimal dialysis.

I look forward to any comments you might add on my second post on this issue going over some of the physiological constraints to large volume ultrafiltration in short periods of time.

[Mriam Lippel Blum]

Dr. Prince - I can certainly understand patients not wanting to spend one more minute on dialysis, especially since most dialysis units are miserable places to get treatment and you will not likely understand that until you have been there as a patient (but I hope you never have to be.) There are few centers set up to be really comfortable and with amenities that would make it more likely that someone would consider spending any more time there than the minumum.

As a dialyzor I chose to increase my time on the machine even when I was on in-center after doing my own research into the matter. I received no counseling from any nephrologist in regards to this. In fact, my experiences with nephrologists for over 20 yrs. is that most seem to expect someone else to do the real educating of their patients. I also the one who found out about and pushed for home hemo. I now dialyze 6 days a week/four hours a day but I'm at home and it's a helluva lot better than any dialysis center.

[Simon Prince]

Dr Laird- Thank you.. and yes, I share your enthusiasm for improved dialysis. If I were on dialysis, as I have shared with my patients.. my preference would be for home hemo.. which brings me to Mriam....

Mriam- I think one issue I had initially with a post was the sweeping generalizations. This isn't to discount your expierence. Nor, is it Dr Laird's with the training of nephrologists... or even mine for non-compliant patients. I have a great deal of respect and empathy for dialysis patients. My experience is that patients like you.. at least where I practice, are in the minority. I do however go over all appropriate options with my patients and do my best to educate each one. I prefer my patients to have transplant evaluations as soon as possible and I have said numerous times to patients that if I were on hemo I'd prefer home hemodialysis. I believe it is a better modality... when feasible.

[Dori]

Dr. Prince, if, as you say, "Most of the patients I come into contact with are not as enlightened and receptive to the concept of more dialysis being beneficial," whose responsibility is that? Don't YOU bear some as the physician of record? It's not as if you have to sit down with each patient for an hour and do this personally. You could send them to Kidney School (http://www.kidneyschool.org), which is free, based on research, easy to read, and available as pdfs for your staff to give patients who don't go online.

IMHO, Peter NAILED the problem in his Part II when he said, "Simply put, short dialysis sessions which require the sudden, violent depletion of the vascular compartment are the primary causation of intradialytic hypotension." THIS (not patient failure to "comply" with an impossible regimen made even more impossible by sodium modeling that leaves patients thirsty) is the problem we need to solve, and making standard in-center HD the treatment of LAST resort is one way to solve it.

[Pat Colongione]

Dr. Prince, One simple thing that in-center Doctors and nurses forget that to keep patients BP's from bottoming out they use sodium profiling. That adds Salt!!!! When my husband use to come home from incenter dialysis he could drink all day and the next day. When he went back they would have to pull 5K or more off. Which is not a good situation, as you all know. But once we were home and on nocturnal with Nxstage that went away. Even when we were on nocturnal at home with the conventional machine I had troble with him. I would have to take off sometimes 2K. Now on Nxstage most nights it isn't even 1/2K. That profiling really makes a difference.
I also agree with Peter in his Part II. I also agree with Dori.
Pat

[Peter Laird, MD]

Pat, your insight is always appreciated. Here is one more aspect of using sodium profiling which increases the sodium mass leading to thirst and thus much of the interdialytic weight gain is once again iatrogenic. This has actually been documented in the medical literature:

Current sodium profiles do not have the aim of achieving net zero sodium balance, which could potentially lead to excess in sodium mass and increase the risk of long- term complications. Attaining the optimal total body sodium content should become just as important as achieving correct dry weight in practice (Palmer, 2001).

http://goliath.ecnext.com/coms2/gi_0199-6971035/Sodium-profiling-the-key-to.html

Sodium profiling came about as a solution to intradialytic hypotension and is a further example of treating a complication that could be prevented. The failed fast and violent depletion of the intravascular department by American style dialysis is the problem generated by financial factors. What a slap in the face to a patient that tries to adhere to salt restrictions only to become salt replete sitting in his dialysis chair and then having the dietician scold him again. Anyone who has experienced the thirst of excessive salt in a dialysis patient would never again expose their patients to a net increase in sodium during dialysis.

As an example, my wife dutifully cooked a pot roast with absolutely no salt. Even though I actually enjoy a low salt diet, this was one dish the simply had to have just a little bit of salt to bring out all of the texture of the vegetables and meat. I added just a couple of small shakes. I was quite surprised that this tiny addition of salt left me thirsty for hours. What then of the nephrologist that uses sodium profiling and increases the sodium mass of their patients and then scold the patient for imbibing in too much fluids. Yes, salt restriction is important for patients and those caring for them as well.

We will only achieve improved results when we recognize the iatrogenic component to some of the common or usual dialysis related complications. If it wasn't killing people, it would be good entertainment on the level of Monty Python, but indeed, it is killing people and it is no joke.

[Miriam Lippel Blum]

When I was on in-center hemo I complied with both the draconion sodium and fluid limitations. Not using sodium was not that hard, but the sodium modeling during treatments left me incredibly thirsty. Trying to fight that kind of overwhelming thirst is torturous, and I do not use the word lightly. I have no such problems on daily home hemo.

[Georgia Rohan]

I lost all kidney function in 1991 and eat a low salt diet, but I must use sodium modelling due to intradyalitic hypotension. Unbelievably, my heart is still strong. I run at a pump speed of 375 and have, in the past, voluntarily increased my run time to 6 hours to try to mimic the benefits of nocturnal - 8 hour - treatments. I live in WNC and have been attempting to get nocturnal started here for 3 years with no success. Despite its being acknowledged as a superior modality, with ratings similar to home hemo, the doctors don't want to round at night, they feel it is harder to staff, and won't give it a go. It is obvious to me that home hemo is championed because it has better outcomes, but it is hard to believe it does not have something to do with cost - it is cheaper if the patient does it at home. Shame on the American renal physician community for allowing high flow rates and letting the patient bear the brunt of the volume shifts. Why are we low in clinical outcomes??? I am compliant with my diet and fluid goals and achieve excellent success and have for twenty years. However, I don't know how long I can survive 4 hour treatments. WE NEED MORE NOCTURNAL UNITS NOW. Docs, please bear up. There are 10 docs in my nephrology office and if they rotated, they would have to round at night only once every few months. PLEASE PLEASE realize not every one can do home hemo and nocturnal is desperately needed.

[Bill Peckham]

Georgia I hope you can gain access to your preferred modality. It shouldn't be so hard to get an incenter nocturnal program started but that is (was ( I think my provider will start one soon)) my experience too.

I believe the new payment system rewards an every other day schedule in ways the previous payment system did not. Clinically an EOD nocturnal schedule would provide a healthy dose of dialysis. I think the business incentives/the business model supports an EOD incenter nocturnal program, I think the clinical evidence supports an EOD incenter nocturnal program, yet I know of not a single one.

I think all that can be done is to fight for one unit at time, one program at a time. Keep up the good fight Georgia.

[Peter Laird, MD]

Bill, EOD is the one model that makes absolute sense since it does not involve adding any facilities at all. The avoidable number of deaths with 4 hours thrice weekly is a testament to our lack of care for dialysis patients. The data on increased deaths after the long weekend is a well known fact that no one has addressed to date. It is part of the national shame of America's ESRD program.

[John Agar]

from Georgia

... 'there are 10 docs in my nephrology office and if they rotated, they would have to round at night only once every few months" ...

Why?

You ARE an odd lot over there!

Why round at all? OK ... I know there is something about 'the dollar' underpinning all this nonsense, but here, in Australia - and in the UK too ... and elsewhere - we see our stable, well dialysis patients once every 2 months (facility-based) and once every 2-3 months (home-based) with bloods pre- and post-dialysis staff-taken (facility) or self-taken and self-spun with a home centrifuge (home), and we get paid $70 per visit. By my reckoning, that's +/- $300 - $450/year/patient, paid by the government where the patient is covered by his/her national universal insurance and not (or minimally) out of pocket.

And, that's it!

Why, if you (the dialysis patient) are well, do you need more? You don't. You want us (health professionals) out of your life, not running it.

Sure, if you are unwell and need weekly review ... we'll do that ... or monthly ... whatever frequency is clinically required. But, 90% of dialysis patients (a 'guesstimate' based on experience) do not need that. 2-3 monthly is enough, is sensible, 'collects' whatever problems need sorting and, lets face it, knowing the vagaries of biochemistry are such that day-to-day, or week-to-week perturbations are normal, happen, and are commonly better left un-pottered with, 2-3 monthly for most patients is wise.

So ... back to Georgia's comment ...

Why 'round' at night at all? We don't 'round' on our home NHD patients ... and, at my unit, 30% of all hemodialysis is at home (35/115). I'd have to chock up a fair petrol bill if I were to 'round' at home!

Why round, just because a patient is in an overnight dialysis unit? It makes no sense at all. If the patient is well ... leave them alone to sleep ... isn't that why they are there? To sleep on dialysis so they can be in a position to work ... or apply for work ... the next day?

If the patient isn't ... well, we have to sort out why ... but 'rounding' won't do that.

I believe that NO patient can be adequately assessed while ON dialysis ... they need a cold, calculating, thoughtful office review.

'Rounding', to me, is like a red rag to a bull. Either the patient is well, and should be left alone and NOT rounded on ... or the patient isn't well, and should be thoughtfully reviewed in the office. We DO do paper 'rounds' with out juniors, once every 6 weeks on all patients where we review charts and bloods and dialysis parameters ... as much to teach as to 'do' stuff, but daily, weekly, every-dialysis rounds? Phttt! Sometimes I wonder if 'rounding' is a way of getting paid in the US? I can see little other benefit.

Maybe I have been a little 'inflammatory' here but, really.

[Anna Bennett]

Dr. Agar, I think that your words could be misunderstood if not taken in the correct context. They aren't inflammatory, more to the point, they are a clarion in the difference between a chronic condition and an acute condition.

Rounding is needed. It is needed in an acute dialysis center, it is needed in a transplant center. In any place where a patient is unstable, I want to know that my medical team is on the same page. In a hospital, I want to know that my case is reviewed often. I say in that scenario, round and round often.

But in a chronic dialysis facility? We need to know that the interdisciplinary team is on the same page, that the dialyzor is engaged, and that they are receiving the best possible care. That could be accomplished in other ways than sitting around a table or going chair to chair and discussing the person and their diagnosis/prognosis/course of therapy on a daily basis.

I think that you are seeing that the American model is flawed in many ways. Dialysis facilities need not replicate hospitals exactly (especially those with a stable population) BUT the interdisciplinary team HAS to be on top form. Communication is key to all of this. And creating a model of care that provides the best possible care that integrates the dialyzor as a part of the care team should be a goal.

I believe that shift level rounding should be done on incident patients. I believe that there should be a monthly meeting (of some sort) of at least the nephrologist with the dialyzor to discuss treatment. But in the classic sense of "rounding" isn't that what we have with chart review in chronic situations?

Australia is well ahead in economising dialysis and still providing better outcomes than the USA. We have a lot to learn, but some of that is simply learning to define/refine our vocabulary and practices in a chronic situation. (oh, and dealing with the greed/profit element as well)

[Anna Bennett]

Oh, and I need to add. The reality is that in today's environment "rounding" in dialysis units is hypothetical. Most patients complain that they can never see a nephrologist, and when they do "Round" is is 30 seconds near their chair once a month (billable).

In practice, over rounding is not really an issue with medical staff in chronic out patient facilities. We have almost 400,000 people on dialysis in the United States and around 8,000 Nephrologists. We need all the help we can get.

[Bruce]

Lower mortality (12%) in Italy vs. US (20%), despite actually lower average Kt/v than in US in the survey.

Partially a result of far lower diabetic population on dialysis, but *also* attributed to mandatory "nephrologist on site" in Italian units. The point is that large margin for improvement can still be found, even within roughly equivalent dialyzing.

http://www.thescientificworld.com/TSW/TOC/DownloadPdf.asp?ArticleId=3197