Nephrology Dialysis Transplantation

Nephrology Dialysis Transplantation 2007 22(Supplement 2):ii22-ii44; doi:10.1093/ndt/gfm019

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© The Author [2007]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

EBPG guideline on haemodynamic instability

Jeroen Kooman¹, Ali Basci², Francesco Pizzarelli³, Bernard Canaud⁴, Patrick Haage⁵, Denis Fouque⁶, Klaus Konner⁷, Alejandro Martin-Malo⁸, Luciano Pedrini⁹, James Tattersall¹⁰, Jan Tordoir¹¹, Marianne Vennegoor¹², Christoph Wanner¹³, Piet ter Wee¹⁴ and Raymond Vanholder¹⁵

¹Department of Internal Medicine, division of Nephrology, University Hospital Maastricht, The Netherlands, ²Department of Medicine; division of Nephrology, Ege University Medical Faculty, Izmir, Turkey, ³Nephrology Unit, SM Annunziata Hospital, Florence, Italy, ⁴Nephrology, Dialysis and Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France, ⁵Department of Diagnostic and Interventional Radiology, Helios Klinikum Wuppertal, University Hospital Witten/Herdecke, Germany, ⁶Département de Néphrologie JE 2411-Dénutrition des Maladies Chroniques, Hôpital E Herriot, France, ⁷Medical Faculty University of Cologne, Medicine Clinic I, Hospital Merheim, Germany (retired), ⁸Nephrology Department, Reina Sofia University Hospital, Cordoba, Spain, ⁹Division of Nephrology and Dialysis, Bolognini Hospital, Seriate, Italy, ¹⁰Department of Renal Medicine, St. James's University Hospital, Leeds, UK, ¹¹Department of Surgery, University Hospital Maastricht, The Netherlands, ¹²Department of Nephrology, Nutrition and Dietetics, Guy's and St Thomas’ NHS Foundation Trust, London, UK (retired), ¹³Department of Medicine, Division of Nephrology, University Hospital, Würzburg, Germany, ¹⁴Department of Nephrology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands, and ¹⁵Nephrology Section, Department of Internal Medicine, University Hospital, Ghent, Belgium

Correspondence and offprint requests to: Jeroen P. Kooman, MD, PhD, Department of Internal Medicine, Division of Nephrology, University Hospital Maastricht, PO Box 5800 6202 AZ Maastricht, The Netherlands. Email: jkoo@sint.azm.nl

Outline

Introduction

Definition of intra-dialytic hypotension (IDH)

Incidence of IDH

Relation between IDH and outcome

Patients at risk for IDH

Pathophysiology of IDH

Prevention of IDH

1. Evaluation of the patient

1.1 Assessment of dry weight

1.2 Measurement of blood pressure and heart rate during dialysis

1.3 Cardiac evaluation

2. Lifestyle interventions

2.1 Sodium restriction

2.2 Food and caffeine intake during dialysis

3. Factors relation to the dialysis treatment

3.1 Manipulation of ultrafiltration

3.1.1 Ultrafiltration profiling

3.1.2 Blood volume controlled ultrafiltration

3.2 Dialysate composition

3.2.1 High sodium dialysis and sodium profiling

3.2.2 Dialysate buffer

3.2.3 Dialysate calcium

3.2.4 Other components of dialysate

3.3 Dialysis membranes/contamination of dialysate

3.4 Dialysate temperature

3.5 Convective techniques and isolated ultrafiltration

3.5.1 Convective techniques

3.5.2 Isolated ultrafiltration

3.6 Dialysis duration and frequency

3.7 Switch to peritoneal dialysis

4. Antihypertensive drugs and preventive medication

4.1 Antihypertensive drugs

4.2 Preventive vasoactive agents

4.3 Carnitine

5. Stratified approach to prevent IDH

6. Treatment of IDH

6.1 Trendelenburg position

6.2 Stopping ultrafiltration

6.3 Infusion fluids

6.4 Protocol

Keywords: dialysis; guideline; haemodynamic; hypotension; instability

The first 150 words of the full text of this article appear below.

	Introduction

 
Definition of intra-dialytic hypotension
In the literature, the definition of intra-dialytic hypotension (IDH) is not standardized and differs between various studies. Most definitions however, take into account either a relative or an absolute decline in blood pressure (BP) as well as the presence of specific symptoms. Although no evidence based recommendation regarding the definition of IDH can be given, the EBPG working group stresses that both a reduction in BP, as well as clinical symptoms with need for nursing intervention should be present in order to accept the presence of IDH. Moreover, the definition of IDH should ideally be equal in the literature and different treatment guidelines. Conforming to the K/DOQI guidelines, a proposed definition is a decrease in systolic BP 20 mmHg or a decrease in mean arterial pressure (MAP) by 10 mmHg associated with clinical events and need for nursing interventions.

Incidence of IDH
In reviews, a 20% incidence of intra-dialytic hypotension is widely cited . . . [Full Text of this Article]

	References

 
Relation between IDH and outcome

	References

 
Patients at risk for IDH

	References

 
Pathophysiology of IDH

	References

 

	Prevention of IDH

 
1. Evaluation of the patient
Rationale
Recommendations for research

	References

 
Rationale
Recommendations for research

	References

 
Rationale
Recommendation for research

	References

 

	2. Lifestyle interventions

 
Rationale
Recommendations for research

	References

 
Rationale
Recommendations for research

	References

 

	3. Factors related to the dialysis treatment

 
3.1 Optimizing ultrafiltration: ultrafiltration profiling and blood volume controlled ultrafiltration
Rationale
Recommendations for research

	References

 
Rationale
Recommendation for research

	References

 

	3.2 Dialysate composition

 
3.2.1 Dialysate sodium
Rationale
Recommendation for research

	References

 

	3.2.2 Dialysate buffer

 
Rationale
Recommendations for research

	References

 

	3.2.3 Dialysate calcium

 
Rationale
Recommendations for research

	References

 

	3.2.4 Other dialysate components

 
Rationale
Recommendations for research

	References

 

	3.3 Dialysis membranes and contamination of dialysate

 
Rationale
Recommendations for research

	References

 

	3.4 Dialysate and body temperature

 
Rationale
Recommendations for research

	References

 

	3.5 Convective techniques and isolated ultrafiltration

 
Rationale
Recommendation for research

	References

 
Rationale
Recommendation for research

	References

 

	3.6 Dialysis duration and frequency

 
Rationale
Recommendation for research

	References

 

	3.7 Switch to peritoneal dialysis

 
Rationale
Recommendations for research

	4. Avoidance of antihypertensive drugs and prescription of vasoactive medication before dialysis

 
Rationale
Recommendation for research

	References

 
Rationale
Recommendations for research

	References

 
Recommendations of research

	References

 

	5. Stratified approach to prevent IDH

 
First-line approach
Second-line approach
Third-line approach (only if other treatment options have failed)

	6. Treatment of IDH

 
6.1 Trendelenburg position
Rationale
Recommendation for research
6.2 Stopping ultrafiltration
Rationale
Recommendation for research
6.3 Infusion fluids
Rationale
Summary of evidence
Recommendation for research
6.4 Protocol-based treatment
Rationale
Recommendation for research

	Reference

 

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