RENAL DATA FROM THE ARAB WORLD
|Year : 2010 | Volume
| Issue : 4 | Page : 756-761
|Characteristics of intradialytic hypotension: Experience of agadir center-morocco
I Akhmouch1, A Bahadi1, Y Zajjari2, A Bouzerda3, M Asserraji2, A Alayoud2, D Montasser2, O Moujoud2, T Aattif2, M Kadiri2, N Zemraoui2, D Elkabbaj2, M Hassani2, M El Allam2, M Benyahia2, Z Oualim2
1 Department of Nephrology, 1st Medical and Chirurgical Center, Agadir, Morocco
2 Department of Nephrology, Hemodialysis and Transplantation, Military Hospital, Rabat, Morocco
3 Department of Hemodialysis, and Cardiology, 1st Medical and Chirurgical Center, Agadir, Morocco
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|Date of Web Publication||26-Jun-2010|
| Abstract|| |
We report in this retrospective study the experience of our hemodialysis (HD) center in the incidence of intradialytic hypotension (IDH) over 18 months. We first studied the demographic, clinical, biological and morphological data of our 52 HD patients and compared the characteristics of patients with frequent IDH and those without. We found that factors significantly associated with IDH include diabetes, left ventricular hypertrophy, impaired diastolic function, weight gain and high ultrafiltration rates. Despite these results, further larger studies are required to confirm them.
|How to cite this article:|
Akhmouch I, Bahadi A, Zajjari Y, Bouzerda A, Asserraji M, Alayoud A, Montasser D, Moujoud O, Aattif T, Kadiri M, Zemraoui N, Elkabbaj D, Hassani M, El Allam M, Benyahia M, Oualim Z. Characteristics of intradialytic hypotension: Experience of agadir center-morocco. Saudi J Kidney Dis Transpl 2010;21:756-61
|How to cite this URL:|
Akhmouch I, Bahadi A, Zajjari Y, Bouzerda A, Asserraji M, Alayoud A, Montasser D, Moujoud O, Aattif T, Kadiri M, Zemraoui N, Elkabbaj D, Hassani M, El Allam M, Benyahia M, Oualim Z. Characteristics of intradialytic hypotension: Experience of agadir center-morocco. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Jul 16];21:756-61. Available from: http://www.sjkdt.org/text.asp?2010/21/4/756/64673
| Introduction|| |
Symptomatic intradialytic hypotension (IDH) is a common complication of hemodialysis (HD). Despite significant improvements of HD techniques in the recent years, the frequency of recurrent IDH episodes has remained nearly unchanged with the incidence of 20 to 30% of treatments. , It is a major complication of HD and has a negative impact on health-related quality of life in HD patients. 
IDH is the clinical manifestation of an imbalance between the decrease in plasma volume during dialysis and the counter-regulatory cardiovascular hemodynamic and neurohormonal mechanisms. ,,, Besides factors directly related to the dialysis procedure itself, several patient related characteristics and comorbidities increase the risk of IDH, mainly through impairment of the above compensatory mechanisms, such as age, diabetes, ischemic heart disease, left ventricular hypertrophy and autonomic neuropathy. ,,, In this study, we report our experience with the IDH and the risk factors that may precipitate this event in HD patients.
| Patients and Methods|| |
This is a retrospective study conducted at the Military center of hemodialysis in Agadir, Morocco from 14/05/2007 to 31/12/2008.
We defined IDH as that proposed by the K/ DOQI guidelines and approved by the European renal best practice (ERBP) of hemodynamic instability (IDH by a decrease in systolic blood pressure ≥ 20 mmHg or a decrease in the mean arterial pressure (MAP) by 10 mmHg associated with clinical events and need for nursing interventions). 
We excluded all patients who had one of the following criteria: Age less than 18 years, length of hemodialysis less than 3 months, and duration of hemodialysis session under 3 hours.
We screened the patients for demographic characteristics: age, sex; clinical data: nephropathy, length of hemodialysis, dry weight, blood pressure before and after dialysis, ultrafiltration rate, hours of intradialytic hypotension, interdialytic weight gain, and anti-hypertensive treatment; laboratory data: hemoglobin, CRP, albumin, intact parathyroid hormone 1-84; morphological data: left ventricular hypertrophy, systolic function and diastolic heart.
We defined frequent IDH patients by those who have had more than ten episodes during the time of screening and more than 5% of the number of sessions conducted at the center.
| Statistical Analysis|| |
We performed analysis of data by the "SPSS" in order to select of patients with frequent IDH, and compared with the Student "t" test the demographic, clinical, biological, and morphological data of patients with frequent IDH those with rare IDH. P value <0.05 was considered significant.
| Results|| |
We have included in our study 54 patients. Their demographics are shown in [Table 1].
During the study period, IDH occurred more than 500 times with an average of 9.72 IDH per patient and range from 0 to 54 episodes. Nephropathies, time of the IDH and the intake anti-hypertensive treatment are shown in [Table 2].
Of the 54 patients we have included, 18 patients met these criteria. The comparison of the demographic and clinical data of both groups showed that the factors predisposing to IDH in the population studied are: diabetes, hemodialysis in the recent two years, left ventricular hypertrophy, especially concentric and impaired diastolic function [Table 3].
The comparison of laboratory data between the two groups revealed that the average hemoglobin in patients with frequent IDH was lower than the rare IDH but the difference was not significant [Table 4].
The comparison of conditions of HD sessions revealed that the incidence of IDH increased significantly with increasing interdialytic weight gain, ultrafiltration rate, especially if it was greater than 800 mL/h and with hypertension before the hemodialysis session [Table 5].
| Discussion|| |
The incidence of IDH is estimated at 20%. , More recent papers estimated the incidence from 6 to 27%. , In our study, IDH occurred in less than 5% of all HD sessions done at our center.
It is now clear that the IDH significantly increases the morbidity and mortality in chronic HD,  in particular cardiac, mesenteric, cerebral ischemia, and atrophy of brain frontal lobe. ,,,, The frequency of IDH episodes also influences negatively the life span of arteriovenous fistulas. 
IDH is the result of a decrease in blood volume and an inadequate cardiovascular response to this situation. It depends on the patient and the parameters of the hemodialysis session and its prevention is the action on one or more of these factors.
Only a few studies have investigated the potential factors for the IDH. Tisler et al  found that age, female sex, diabetes, hyperphosphatemia, and presence of ischemic heart disease are encountered in patients with frequent IDH. In our study, the presence of diabetes and duration of HD for less than two years significantly correlated with frequent IDH, while the serum phosphorus levels did not.
The alteration of cardiac function increases the risk of IDH. Similarly to ours, observational studies have found that the IDH was more common in patients with impaired diastolic cardiac function and concentric left ventricular hypertrophy. , In addition, we found that the systolic function, long blamed in hypotension,  did not influence the frequency of IDH,  and arterial blood pressure was higher in the IDH susceptible IDH patients.
On the laboratory level, although hypoalbuminemia has recently been reported as a risk factor for IDH,  we did not find a significant correlation of IDH with low serum albumin levels due to its good levels in our patients. Furthermore, in our study, the hemoglobin in levels did not correlate with the frequent IDH.
Several factors that affect the course of the HD session influence the frequency of IDH. The increased ultarfiltration rate, especially when it exceeds 800 mL/h, is an important determinant of IDH. , Moreover, interdialytic weight gain increases the sensitivity to hypotension because the ultrafiltration rate increases with weight gain, especially when the duration of the HD session remains unchanged. Interdialytic weight gain may be aggravated by many factors such as dry mouth, non-compliance with the prescribed diet, ,,, or uncontrolled diabetes. ,
Finally, food intake during dialysis may result in IDH linked to splanchnic vasodila tion. , However, a recent study in Canada has found no link between food intake and hypotension. 
We conclude that IDH is a common complication during HD sessions, and our study found that the factors predisposing to the IDH included diabetes, recent entry into HD, left ventricular hypertrophy, alteration of cardiac diastolic function, excessive interdialytic weight gain, and high ultrafiltration rate.
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Service de Nephro-Hemodialyse Etat Major General, Agadir
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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