Abstract
The term intradialytic hypertension (IDH) describes a paradoxical rise in blood pressure (BP) during or immediately after the hemodialysis session. Although it was formerly considered a phenomenon without clinical implications, current evidence suggests that IDH may affect up to 15% of hemodialysis patients and exhibit independent associations with future cardiovascular events and all-cause mortality. Furthermore, during the last decade, several studies have tried to elucidate the complex pathophysiological mechanisms responsible for this phenomenon. Volume overload, intradialytic sodium gain, overactivity of the sympathetic-nervous-system and renin-angiotensin-aldosterone system, endothelial dysfunction and dialysis-related electrolyte disturbances have been proposed to be involved in the pathogenesis of the BP increase during hemodialysis. This review attempts to summarize existing evidence on the epidemiology, pathophysiology and clinical characteristics of the distinct phenomenon of IDH.
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References
Bikbov B, Purcell CA, Levey AS, Smith M, Abdoli A, Abebe M, et al. Global, regional, and national burden of chronic kidney disease, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2020;395:709–33.
Saran R, Robinson B, Abbott KC, Agodoa LYC, Bragg-Gresham J, Balkrishnan R, et al. US Renal Data System 2018 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis. 2019;73:A7–A8.
Jager KJ, Fraser SDS. The ascending rank of chronic kidney disease in the global burden of disease study. Nephrol Dial Transpl. 2017;32:ii121–ii128.
Hill NR, Fatoba ST, Oke JL, Hirst JA, O’Callaghan CA, Lasserson DS, et al. Global prevalence of chronic kidney disease - a systematic review and meta-analysis. PLoS One. 2016;11:e0158765.
Nordio M, Limido A, Maggiore U, Nichelatti M, Postorino M, Quintaliani G, et al. Survival in patients treated by long-term dialysis compared with the general population. Am J Kidney Dis. 2012;59:819–28.
Robinson BM, Zhang J, Morgenstern H, Bradbury BD, Ng LJ, McCullough KP, et al. Worldwide, mortality risk is high soon after initiation of hemodialysis. Kidney Int. 2014;85:158–65.
Sarafidis PA, Persu A, Agarwal R, Burnier M, de Leeuw P, Ferro CJ, et al. Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH). Nephrol Dial Transpl. 2017;32:620–40.
Inrig JK. Intradialytic hypertension: a less-recognized cardiovascular complication of hemodialysis. Am J Kidney Dis. 2010;55:580–9.
Georgianos PI, Sarafidis PA, Zoccali C. Intradialysis hypertension in end-stage renal disease patients: clinical epidemiology, pathogenesis, and treatment. Hypertension. 2015;66:456–63.
Inrig JK, Patel UD, Toto RD, Szczech LA. Association of blood pressure increases during hemodialysis with 2-year mortality in incident hemodialysis patients: a secondary analysis of the Dialysis Morbidity and Mortality Wave 2 Study. Am J Kidney Dis. 2009;54:881–90.
Locatelli F, Cavalli A, Tucci B. The growing problem of intradialytic hypertension. Nat Rev Nephrol. 2010;6:41–48.
Van Buren PN. Pathophysiology and implications of intradialytic hypertension. Curr Opin Nephrol Hypertens. 2017;26:303–10.
Amerling R, Cu GA, Dubrow A, Levin NW, Osheroff RJ. Complications during hemodialysis. In: Nissenson AR, Fine RN, Gentile DE (editors), Clinical dialysis, 3rd ed. East Norwalk: Appleton & Lange; 1995:235–67.
Inrig JK, Oddone EZ, Hasselblad V, Gillespie B, Patel UD, Reddan D, et al. Association of intradialytic blood pressure changes with hospitalization and mortality rates in prevalent ESRD patients. Kidney Int. 2007;71:454–61.
Fellner S. Intradialytic hypertension: II. Semin Dial. 1993;6:371–3.
Cirit M, Akçiçek F, Terzioğlu E, Soydaş C, Ok E, Ozbaşli CF, et al. “Paradoxical” rise in blood pressure during ultrafiltration in dialysis patients. Nephrol Dial Transpl. 1995;10:1417–20.
Dorhout Mees EJ. Rise in blood pressure during hemodialysis-ultrafiltration: a “paradoxical” phenomenon? Int J Artif Organs. 1996;19:569–70.
Flythe JE, Chang TI, Gallagher MP, Lindley E, Madero M, Sarafidis PA, et al. Blood pressure and volume management in dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int. 2020;97:861–76.
Inrig JK, Van Buren P, Kim C, Vongpatanasin W, Povsic TJ, Toto R. Probing the mechanisms of intradialytic hypertension: a pilot study targeting endothelial cell dysfunction. Clin J Am Soc Nephrol. 2012;7:1300–9.
Inrig JK, Molina C, D’Silva K, Kim C, Van Buren P, Allen JD, et al. Effect of low versus high dialysate sodium concentration on blood pressure and endothelial-derived vasoregulators during hemodialysis: a randomized crossover study. Am J Kidney Dis. 2015;65:464–73.
Bikos A, Loutradis C, Angeloudi E, Karpetas A, Raptis V, Kalaitzidis R, et al. The effects of nebivolol and irbesartan on postdialysis and ambulatory blood pressure in patients with intradialytic hypertension: a randomized cross-over study. J Hypertens. 2019;37:432–42.
Nair SV, Balasubramanian K, Ramasamy A, Thamizhselvam H, Gharia S, Periasamy S Effect of low dialysate sodium in the management of intradialytic hypertension in maintenance hemodialysis patients: A single-center Indian experience. Hemodial Int Published Online First: 18 March 2021. https://doi.org/10.1111/hdi.12921
Van Buren PN, Kim C, Toto RD, Inrig JK. The prevalence of persistent intradialytic hypertension in a hemodialysis population with extended follow-up. Int J Artif Organs. 2012;35:1031–8.
Assimon MM, Wang L, Flythe JE. Intradialytic hypertension frequency and short-term clinical outcomes among individuals receiving maintenance hemodialysis. Am J Hypertens. 2018;31:329–39.
Park J, Rhee CM, Sim JJ, Kim Y-L, Ricks J, Streja E, et al. A comparative effectiveness research study of the change in blood pressure during hemodialysis treatment and survival. Kidney Int. 2013;84:795–802.
Shamir AR, Karembelkar A, Yabes J, Yao Y, Miskulin D, Gassman J, et al. Association of intradialytic hypertension with left ventricular mass in hypertensive hemodialysis patients enrolled in the blood pressure in dialysis (BID) study. Kidney Blood Press Res. 2018;43:882–92.
Mattos MSR, de C, Lemes HP, Ferreira-Filho SR. Correlation between pre- and post-dialysis blood pressure levels in hemodialysis patients with intradialytic hypertension. Int Urol Nephrol. 2016;48:2095–9.
Ren H, Gong D, He X, Jia F, He Q, Xu B, et al. Evaluation of intradialytic hypertension using bioelectrical impedance combined with echocardiography in maintenance hemodialysis patients. Ther Apher Dial. 2018;22:22–30.
Ali M, Ejaz A, Iram H, Solangi SA, Junejo AM, Solangi SA. Frequency of intradialytic complications in patients of end-stage renal disease on maintenance hemodialysis. Cureus. 2021;13:e12641.
Amira CO, Braimoh RW, Bello BT. Pattern of intradialytic complications at the Lagos University Teaching Hospital. Afr J Med Med Sci. 2012;41:411–6.
Okpa HO, Effa EE, Oparah SK, Chikezie JA, Bisong EM, Mbu PN, et al. Intradialysis blood pressure changes among chronic kidney disease patients on maintenance haemodialysis in a tertiary hospital south - south Nigeria: a 2 year retrospective study. Pan Afr Med J. 2019;33:91.
Egbi OG, Daz AS. Blood pressure changes among patients undergoing hemodialysis in Yenagoa, Nigeria. Niger Med J. 2019;60:290–4.
Islam F, Siddiqui F, Sabir S, Butt B, Qayyum M, Kiani I, et al. Frequencies of acute intra-dialytic complications: a single centre experience. Pak Armed Forces Med J. 2017;67:253–8.
Mahmood A, Aziz K, Ahmed S, Baig Z, Muhammad W, Rahman M. Frequency of acute complications of hemodialysis in adult age group at a tertiary care center. Pak Armed Forces Med J. 2018;68:1219–1214.
Yang C-Y, Yang W-C, Lin Y-P. Postdialysis blood pressure rise predicts long-term outcomes in chronic hemodialysis patients: a four-year prospective observational cohort study. BMC Nephrol. 2012;13:12.
Choi C-Y, Park JS, Yoon KT, Gil HW, Lee EY, Hong SY. Intra-dialytic hypertension is associated with high mortality in hemodialysis patients. PLoS One. 2017;12:e0181060.
Lu J, Zhu M, Liu S, Zhu M, Pang H, Lin X, et al. The relationship between survival rate and intradialytic blood pressure changes in maintenance hemodialysis patients. Ren Fail. 2017;39:417–22.
Kale G, Mali M, Bhangale A, Somani J.Jeloka T, Intradialytic hypertension increases non-access related hospitalization and mortality in maintenance hemodialysis patients. Indian J Nephrol. 2020a;30:85–90.
Zoccali C, Tripepi R, Torino C, Tripepi G, Mallamaci F. Moderator’s view: Ambulatory blood pressure monitoring and home blood pressure for the prognosis, diagnosis and treatment of hypertension in dialysis patients. Nephrol Dial Transpl. 2015;30:1443–8.
Foley RN, Herzog CA, Collins AJ. United States Renal Data System. Blood pressure and long-term mortality in United States hemodialysis patients: USRDS Waves 3 and 4 Study. Kidney Int. 2002;62:1784–90.
Robinson BM, Tong L, Zhang J, Wolfe RA, Goodkin DA, Greenwood RN, et al. Blood pressure levels and mortality risk among hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study. Kidney Int. 2012;82:570–80.
Kovesdy CP, Bleyer AJ, Molnar MZ, Ma JZ, Sim JJ, Cushman WC, et al. Blood pressure and mortality in U.S. veterans with chronic kidney disease: a cohort study. Ann Intern Med. 2013;159:233–42.
Amar J, Vernier I, Rossignol E, Bongard V, Arnaud C, Conte JJ, et al. Nocturnal blood pressure and 24-hour pulse pressure are potent indicators of mortality in hemodialysis patients. Kidney Int. 2000;57:2485–91.
Agarwal R, Brim NJ, Mahenthiran J, Andersen MJ, Saha C. Out-of-hemodialysis-unit blood pressure is a superior determinant of left ventricular hypertrophy. Hypertension. 2006;47:62–68.
Agarwal R. Blood pressure and mortality among hemodialysis patients. Hypertension. 2010;55:762–8.
Parati G, Ochoa JE, Bilo G, Agarwal R, Covic A, Dekker FW, et al. Hypertension in chronic kidney disease part 1: out-of-office blood pressure monitoring: methods, thresholds, and patterns. Hypertension. 2016;67:1093–101.
Van Buren PN, Kim C, Toto R, Inrig JK. Intradialytic hypertension and the association with interdialytic ambulatory blood pressure. Clin J Am Soc Nephrol. 2011;6:1684–91.
Bikos A, Angeloudi E, Memmos E, Loutradis C, Karpetas A, Ginikopoulou E, et al. A comparative study of short-term blood pressure variability in hemodialysis patients with and without intradialytic hypertension. Am J Nephrol. 2018;48:295–305.
Gũnal AI, Karaca I, Celiker H, Ilkay E, Duman S. Paradoxical rise in blood pressure during ultrafiltration is caused by increased cardiac output. J Nephrol. 2002;15:42–47.
Teng J, Tian J, Lv W-L, Zhang X-Y, Zou J-Z, Fang Y, et al. Inappropriately elevated endothelin-1 plays a role in the pathogenesis of intradialytic hypertension. Hemodial Int. 2015;19:279–86.
Nongnuch A, Campbell N, Stern E, El-Kateb S, Fuentes L, Davenport A. Increased postdialysis systolic blood pressure is associated with extracellular overhydration in hemodialysis outpatients. Kidney Int. 2015;87:452–7.
Van Buren PN, Zhou Y, Neyra JA, Xiao G, Vongpatanasin W, Inrig J, et al. Extracellular volume overload and increased vasoconstriction in patients with recurrent intradialytic hypertension. Kidney Blood Press Res. 2016;41:802–14.
Sebastian S, Filmalter C, Harvey J, Chothia M-Y. Intradialytic hypertension during chronic haemodialysis and subclinical fluid overload assessed by bioimpedance spectroscopy. Clin Kidney J. 2016;9:636–43.
Loutradis C, Sarafidis PA, Ferro CJ, Zoccali C. Volume overload in hemodialysis: diagnosis, cardiovascular consequences, and management. Nephrol Dial Transpl. 2021;36:2182–93.
Agarwal R, Light RP. Intradialytic hypertension is a marker of volume excess. Nephrol Dial Transpl. 2010;25:3355–61.
Flammer AJ, Anderson T, Celermajer DS, Creager MA, Deanfield J, Ganz P, et al. The assessment of endothelial function: from research into clinical practice. Circulation. 2012;126:753–67.
Raj DSC, Vincent B, Simpson K, Sato E, Jones KL, Welbourne TC, et al. Hemodynamic changes during hemodialysis: role of nitric oxide and endothelin. Kidney Int. 2002;61:697–704.
Chou K-J, Lee P-T, Chen C-L, Chiou C-W, Hsu C-Y, Chung H-M, et al. Physiological changes during hemodialysis in patients with intradialysis hypertension. Kidney Int. 2006;69:1833–8.
El-Shafey EM, El-Nagar GF, Selim MF, El-Sorogy HA, Sabry AA. Is there a role for endothelin-1 in the hemodynamic changes during hemodialysis? Clin Exp Nephrol. 2008;12:370–5.
Inrig JK, Van Buren P, Kim C, Vongpatanasin W, Povsic TJ, Toto RD. Intradialytic hypertension and its association with endothelial cell dysfunction. Clin J Am Soc Nephrol. 2011;6:2016–24.
Bazzato G, Coli U, Landini S, Lucatello S, Fracasso A, Morachiello P, et al. Prevention of intra- and postdialytic hypertensive crises by captopril. Contrib Nephrol. 1984;41:292–8.
Rubinger D, Backenroth R, Sapoznikov D. Sympathetic activation and baroreflex function during intradialytic hypertensive episodes. PLoS One. 2012;7:e36943.
Park SH, Fonkoue IT, Li Y, DaCosta DR, Middlekauff HR, Park J. Augmented cardiopulmonary baroreflex sensitivity in intradialytic hypertension. Kidney Int Rep. 2018;3:1394–402.
Meyring-Wösten A, Luo Y, Zhang H, Preciado P, Thijssen S, Wang Y, et al. Intradialytic hypertension is associated with low intradialytic arterial oxygen saturation. Nephrol Dial Transpl. 2018;33:1040–5.
Song JH, Park GH, Lee SY, Lee SW, Lee SW, Kim M-J. Effect of sodium balance and the combination of ultrafiltration profile during sodium profiling hemodialysis on the maintenance of the quality of dialysis and sodium and fluid balances. J Am Soc Nephrol. 2005;16:237–46.
Oberleithner H, Riethmüller C, Schillers H, MacGregor GA, de Wardener HE, Hausberg M. Plasma sodium stiffens vascular endothelium and reduces nitric oxide release. Proc Natl Acad Sci USA. 2007;104:16281–6.
Movilli E, Camerini C, Gaggia P, Zubani R, Feller P, Poiatti P, et al. Role of dialysis sodium gradient on intradialytic hypertension: an observational study. Am J Nephrol. 2013;38:413–9.
Haddy FJ, Vanhoutte PM, Feletou M. Role of potassium in regulating blood flow and blood pressure. Am J Physiol Regul Integr Comp Physiol. 2006;290:R546–552.
Amberg GC, Bonev AD, Rossow CF, Nelson MT, Santana LF. Modulation of the molecular composition of large conductance, Ca(2+) activated K(+) channels in vascular smooth muscle during hypertension. J Clin Invest. 2003;112:717–24.
Dolson GM, Ellis KJ, Bernardo MV, Prakash R, Adrogué HJ. Acute decreases in serum potassium augment blood pressure. Am J Kidney Dis. 1995;26:321–6.
Gabutti L, Bianchi G, Soldini D, Marone C, Burnier M. Haemodynamic consequences of changing bicarbonate and calcium concentrations in haemodialysis fluids. Nephrol Dial Transpl. 2009;24:973–81.
LeBeouf A, Mac-Way F, Utescu MS, Chbinou N, Douville P, Desmeules S, et al. Effects of acute variation of dialysate calcium concentrations on arterial stiffness and aortic pressure waveform. Nephrol Dial Transpl. 2009;24:3788–94.
Brunelli SM, Sibbel S, Do TP, Cooper K, Bradbury BD. Facility dialysate calcium practices and clinical outcomes among patients receiving hemodialysis: a retrospective observational study. Am J Kidney Dis. 2015;66:655–65.
Sarafidis PA, Loutradis C, Karpetas A, Tzanis G, Piperidou A, Koutroumpas G, et al. Ambulatory Pulse Wave Velocity Is a Stronger Predictor of Cardiovascular Events and All-Cause Mortality Than Office and Ambulatory Blood Pressure in Hemodialysis Patients. Hypertension. 2017;70:148–57.
Georgianos PI, Sarafidis PA, Lasaridis AN. Arterial stiffness: a novel cardiovascular risk factor in kidney disease patients. Curr Vasc Pharm. 2015;13:229–38.
Georgianos PI, Sarafidis PA, Malindretos P, Nikolaidis P, Lasaridis AN. Hemodialysis reduces augmentation index but not aortic or brachial pulse wave velocity in dialysis-requiring patients. Am J Nephrol. 2011;34:407–14.
Mourad A, Khoshdel A, Carney S, Gillies A, Jones B, Nanra R, et al. Haemodialysis-unresponsive blood pressure: cardiovascular mortality predictor? Nephrol (Carlton). 2005;10:438–41.
Raikou VD, Kyriaki D. The association between intradialytic hypertension and metabolic disorders in end stage renal disease. Int J Hypertens. 2018;2018:1681056.
Georgianos PI, Mpoutsiouki F, Sabani E, Stamatiadis DN, Liakopoulos V, Balaskas EV, et al. Hemodialysis patients with intradialytic rise in blood pressure display higher baseline aortic stiffness and negligible drop in augmentation index with dialysis. Int Urol Nephrol. 2016;48:601–8.
Kidney Disease Outcomes Quality Initiative (K/DOQI). K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. Am J Kidney Dis. 2004;43:S1–290.
Boyle SM, Berns JS. Erythropoietin and resistant hypertension in CKD. Semin Nephrol. 2014;34:540–9.
Kang DH, Yoon KI, Han DS. Acute effects of recombinant human erythropoietin on plasma levels of proendothelin-1 and endothelin-1 in haemodialysis patients. Nephrol Dial Transpl. 1998;13:2877–83.
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Iatridi, F., Theodorakopoulou, M.P., Papagianni, A. et al. Intradialytic hypertension: epidemiology and pathophysiology of a silent killer. Hypertens Res 45, 1713–1725 (2022). https://doi.org/10.1038/s41440-022-01001-3
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DOI: https://doi.org/10.1038/s41440-022-01001-3
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